Large-scale insulin overdoses from syringe-related errors: Analysis and insights across 47 hospitals (30 January 2026)

Summary

Although insulin is used daily by millions of people around the world, it is considered a high-alert drug that has been associated with more medication errors than any other medication type or class. One challenge in administering insulin is that it is measured in “units” rather than milliliters (mL), requiring unique insulin syringes with the appropriate markings. Using a syringe intended for other medication to administer insulin could lead to an overdose of up to 100 times the intended dose.

To identify contributing factors and develop strategies to reduce the risk of wrong dose errors related to the use or selection of syringes, researchers focused on event reports submitted by Pennsylvania facilities in the USA over the last decade that involved U-100 insulin and syringe-related issues resulting in dosing errors or near misses.

Some of the key takeaways of their detailed study—which encompassed 74 reports from 47 facilities—are that over a third of errors that reached the patient were serious events and among reports specifying syringe volume, 73.8% involved a 1-mL syringe. Contributing factors included using the wrong syringe due to improper syringe storage, similar cap color or packaging, and provider’s lack of experience. Variability in hospital insulin protocols and formularies was also observed. The authors encourage facilities to evaluate and standardize their existing insulin protocols and formularies, and implement the suggested safety strategies for preventing syringe-related insulin dose errors.

Content