Medication Errors: Confusion between look-alike syringes

American Nursing Student
Nursing Center

When different products are packaged in similar ways, they can easily be confused. One recent example is tuberculin (TB) syringes (with affixed 25-gauge needles) being mistaken for insulin syringes. Although the TB syringe--typically used for subcutaneous injections--used to have a blue needle hub and label, recently it's been packaged in a white wrapper with black and orange print with an orange plunger tip--the same color used on insulin syringes for many years. Because of these similarities, more than one nurse has picked up the wrong syringe.

To prevent more medication errors caused by the similarity in these products, hospital pharmacies should store insulin syringes separately from all other syringes or use different color TB syringes--such as ones with a 26-gauge (brown) or 27-gauge (gray) needle--so that the only orange-colored syringe caps are those on insulin syringes. In addition, the facility's purchasing agents might explore alternate products.