The vials look similar, both are dosed in units, and both are sometimes added to total parenteral nutrition bags. The Institute for Safe Medication Practices (ISMP) has issued an error alert on heparin-insulin confusion following reports that insulin, rather than heparin, was unintentionally added to infant TPN in several states, with 2 fatal outcomes.1 In New Jersey, a blood glucose level of 17 mg/dL was found in a preterm infant in an NICU 6 hours after a TPN infusion had been started. Despite multiple boluses of glucose and infusion of dextrose 20%, the hypoglycemia did not resolve until the TPN was discontinued. The remaining TPN was sent for analysis, which revealed that the fluid contained insulin, instead of heparin. Health professionals in neonatal intensive care units are urged to check with TPN suppliers, whether their hospital pharmacy or outside vendor, to inquire about steps being taken to prevent this type of error. In addition, if unexpected and unexplained cases of hypoglycemia occur, the possibility of a medication error should be considered as part of the differential diagnosis, and the following steps should be taken:

* Discontinue current infusion and hang new solution

* Treat the baby as necessary for hypoglycemia

* Have the original bag analyzed for unintended additives

The most common factors associated with these mix-ups seems to be: similar packaging of insulin and heparin in 10-mL vials, and placement of insulin and heparin vials, both typically used each shift/day, next to each other on a counter, drug cart, or under a pharmacy IV admixture hood; and mental slips leading to confusion between heparin and insulin, especially because both drugs are dosed in units.1

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