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We are giving a lot more insulin drips than we used to. We add large red High Alert stickers to each insulin bag (and other drugs). Our IV label is large, so the High Alert sticker goes on the other side of the IV bag.We just had an error when an anesthesiologist infused the 100 unit insulin bag over 30 min. (thinking it was an antibiotic). Dextrose given, Pt unharmed.As a result, we will start sending all insulin drips (and other drugs) in "High Alert" Zip-Lock bags. We still see error potential in this High Alert sticker & bag method. Are there any other good systems that help prevent accidental insulin infusion?

John H. Eastham, Pharm.D.
Medication Safety Specialist
Palomar Pomerado Health
john_eastham@yahoo.com