Letters to the editor

From the Editor: I have received much communication regarding insulin vial
configuration from health care providers and lay-persons, with unanimous
consensus that different types of insulins should be packaged in differently
shaped vials for greater safety. If vials were shaped differently, both blind
and sighted diabetics could identify types of insulin by touch. Container
design changes would definitely help the blind. Moreover, such changes would
also benefit the sighted. The following letters support this premise. 

December 23, 1994

Dear Ed,
Just a note to thank you for helping with the insulin vial shapes and
markings.
From my letter to the Commissioner, Dr. Kessler, you can see what RNs and MDs
are facing with the small print on the vials. Sometimes the print is so tiny,
I use a magnifying glass to identify the words. It is really unsafe and I
blame drug companies for not being creative enough to overcome this problem.
I have diabetes type II and I appreciate very much what you are doing for us.
I am not the only nurse who complains of this matter  but I am one of the
more vocal.
I really appreciate this opportunity to write to the Food and Drug
Administration to voice my complaint  you've made it very convenient for me.
I will give the drug company credit for using color codings on some drugs  it
can only help the sighted  right?

Again, appreciatively,
Clara Lipe, RN
La Palma, CA
 
     
 
Published in a past Voice, the following is self explanatory. Due to its
clarity, it is being recarried.

February 2, 1993

Dear Mr. Bryant:
A recent issue of Voice of the Diabetic was forwarded to me by one of your
readers. The article about insulin vial configurations caught my eye. Our
institute has an agreement with the United Sates Pharmacopeia, Inc. to operate
the Medication Error Reporting Program (USP MERP), a system used by health
care practitioners, to voluntarily and confidentially report mistakes they or
their colleagues have made. The idea is to educate one another about medical
errors in the hope that such knowledge will help reduce the incidence.
We are in support of your proposal to change insulin vial configurations in
order to reduce dosage errors. This would be helpful to health care
practitioners as well as diabetic patients. Unfortunately, mistakes in
choosing proper containers are occasionally made by practitioners, so we too
could use the help that tactile features would provide. For example, we have
had mix-ups reported where vials of regular insulin were improperly placed
into an NPH cardboard outer package and later used accidentally for NPH. While
we recommend that the cardboard box be discarded when a new vial is opened,
shaping the various insulin vials differently would add an important layer of
safety.
We are aware of other medication containers that provide tactile barriers
against error. The Burroughs Wellcome Company packages the muscle relaxant
Tracrium in a hexagonally shaped vial. Since this drug is used to induce
complete paralysis during surgery, accidentally giving it to someone who is
not simultaneously receiving artificial ventilation will cause respiratory
arrest. The odd shape reduces the possibility that Tracrium will ever be
confused with another drug.
Thank you for your efforts to improve the level of safety of insulin
administration. Please let me know if I can be of assistance.

Sincerely yours,
Michael Cohen, MS, FASHP
President
Institute for Safe Medication Practices, Inc.
Huntingdon Valley, PAn
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