You’d be surprised how many medication errors involve patients identify their medication based on the overall appearance of the container and where it is usually stored, never actually reading the label. Doing that is a set up for errors.
A man with diabetes mixed up two different insulin products that he takes. He mixed up his long-acting insulin called Lantus and his rapid-acting insulin, Apidra. He stored the insulin vials separately in his refrigerator, normally keeping Lantus in the butter bin and Apidra on one of the main shelves. However, his wife recently cleaned out the refrigerator and accidently switched the two. She put the rapid-acting Apidra in the butter bin and the long-acting Lantus on the main shelf.
The man normally gave himself 40 units of Lantus plus, depending on blood sugar testing, just a few units of Apidra right before meals. But unaware of the switch made by his wife, the next time the man went to use his Lantus he grabbed Apidra instead. He didn’t read the label. Using an insulin syringe, he drew up and gave himself Apidra 40 units, and went on with his day. The next thing he remembered was 2 hours later when he woke up and was lying on the ground, next to his truck, surrounded by paramedics. Because he had taken his rapid-acting insulin, his blood sugar dropped too quickly. Had he taken the correct long-acting insulin, the medicine would have been used by his body gradually throughout the day.
The man is thankful that he wasn’t driving when he passed out. He said that while he has “learned his lesson,” he wanted to share his story so others could learn from his mistake.