April 30, 2016 - On this D Day of flu immunization in Brasil, awareness is needed on confusion between insulin and vaccines as stated by an ISMP Brasil Alert following a serial error that occurred last Thursday 28 April 2016 in the community hospital of Maringá (North Paraná) where fifty employees received a dose of insulin by error instead of the influenza vaccine.

The nurse in charge of the vaccination of the hospital staff took the wrong box in the refrigerator where insulin and vaccine against influenza were stored. She has been confused with the packaging and administered the wrong substance to her colleagues and to herself. The administration of vaccines began at 9 am, and the error was spotted around 10am. Given the error, staff members who have been "vaccinated" with insulin received a glucose injection. To avoid problems, all were hospitalized and remained under observation until 21h. So far, fortunately, no employee showed any adverse effects.

Although having already alerted healthcare professionals about the risks of errors involving vaccines in a bulletin on insulins and on neuromuscular blockers, ISMP Brasil takes advantage of a National Safety Alert on this confusion between insulin and influenza vaccines occurrence to highlight the need for learning front of the internally identified errors and other health institutions; and to present some recommendations to prevent medication errors involving vaccines.

It is unfortunate that these errors continue to occur while they are long known: similar mix-ups between vaccines and insulin have led to the deaths of 21 children in 1997, others have been reported and published:

• World Health Organization "Global manual on surveillance of adverse events following immunization" 2014; page 21.
• Institute for Safe Medication Practices (ISMP) "What else is stored in a refrigerator with influenza vaccine?" ISMP Medication Safety Alert! Acute Care 2014; 19 (24): 1.
• Shanks L et coll. "Learning without Borders: A Review of the Implementation of Medical ErrorReporting in Medecins Sans Frontieres" PLoS One 2015; 10 (9): e0137158.

And fatal confusions involving muscle relaxants are more serious and more worrying. The International Medication Safety Network (IMSN) has made it the starting point of its International Position Statement on Safer Vaccine Packaging and Label Design, calling on 14 December 2015 for greater worldwide attention to the problem of unsafe design of vaccine packaging and labelling.

Although without serious consequences for the health professionals who were the subject of this vaccination campaign, the error that occurred in Brasil recalls the urgency to understand and implement the proposals of the IMSN. Again and again, the IMSN position statement calls on healthcare professionals, pharmaceutical companies, technology vendors, professional organizations, and regulatory/standard-setting organizations to help improve vaccine safety and efficacy. Read on...