16 Students Got Insulin By Mistake, How To Prevent This


You never want to hear the words, “accidentally gave you insulin.”

But that’s apparently what happened to 16 students at an Indianapolis, Indiana, area high school. They were supposed to get tuberculosis (TB) tests as part of a health sciences program at the McKenzie Center for Innovation and Technology but instead got “small doses” of insulin.

Here is a Fox 59 report on the situation:

The Community Health Network, which handled the TB skin testing, posted the following on Facebook after the mishap:

Of course, accidentally getting a “small dose” is better than accidentally getting a “big dose” or a “massive dose” or an “oh-my-goodness dose.” The Mantoux tuberculin skin test typically involves injecting a fairly small amount of fluid, called tuberculin, into the skin of your lower arm to see if you react over the next day or two. Thus, fortunately this switcheroo didn’t involve a larger amount of medication injected into veins.

Your pancreas naturally secretes insulin to regulate the movement and metabolism of glucose. It helps glucose move from your bloodstream into the cells of your body. Too much insulin can then result in your blood sugar levels dropping too low, which can lead to dizziness, fatigue, mental status changes, seizures, and even loss of consciousness. If the students were otherwise healthy and did indeed get only small doses of insulin, they may not be affected much.

Nonetheless, this is an example of how mistakes can happen even with what seems to be a relatively low risk test. Mistakes may be part of life but getting fries when you wanted onion rings is not the same as getting the wrong medication. Never assume that a clinic, hospital, pharmacy, or any other type of health care system is going to do things right. When getting any type of health care procedure, always take the following precautions:

  1. Make sure that everything is reasonably organized with good record keeping. A restaurant’s bathroom can tell you a lot about what’s happening in its kitchen. Similarly, in a clinic or hospital, look for signs that things aren’t in order, such as poor appointment services or dirty waiting areas.
  2. Ask for the credentials, experience, and title of whomever is taking care of you. Do this for everyone, regardless of what they are wearing, how they appear, what their gender, race, ethnicity, or age may be, or how they make you feel. Some health care settings may try to save costs by having unqualified and under-trained people taking care of patients. If the person gets offended or defensive when you ask, explain that you do this to everyone.
  3. Tell the person to explain everything that he or she is doing. There should be no special sauce or secret recipe. If the explanation includes too many words like “stuff” or “thingamajig,” consider asking for someone else to help.
  4. Inquire about how many times the person has done what he or she is about to do. Don’t accept vague answers like “more than once” or “a lot.” Beware of answers like “about to be once” or “do you mean before or after my ‘lost years’ happened?”
  5. Check to see if the person is taking things out of new packaging. Medications and medical devices are not underwear. You can’t just throw them into a regular washing machine after use. They either need to be brand new or have gone through proper special cleaning.
  6. Make sure that the person shows you the bottle or container of anything that he or she is giving you. Don’t just take the person’s word for it. Look for anything suspicious such as a name that does not match what you are supposed to be getting or the word “ketchup.”
  7. Be concerned about any push-back. As long as you make your requests politely and respectfully, you shouldn’t get resistance. If you do, consider them possible red flags.

Remember that mistakes can occur even in places with the “best” reputations. Just because other patients haven’t had issues doesn’t mean that you won’t as well. Not only does the right system have to be in place, the right individuals need to be taking care of you and using the appropriate amount of attention. At this time, it isn’t completely clear how the Community Health Network mishap occurred, as the organization has so far responded to Facebook inquiries by stating, “we’re investigating what occurred and will take immediate action to update the necessary procedures,” and, “at this time we’re still undergoing an evaluation and will review processes to prevent the error from happening again.”

Again, be vigilant. Know and confirm what you are getting and that you are getting it from people who really know what they are doing. Otherwise you may get an unpleasant dose of reality.

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