[DoughtyOne]

Someone carelessly placed an Insulin vial in the wrong area.

Someone carelessly picked up a vial and injected people without verifying the substance in that vial.

The last person to touch it, use it, pulled a major screw-up.

[cherry]

when we give vacinations here in the hospital, they are all separate one time use vials, and you have to scan in the lot number, manufacturer etc..

its hard to see how this could happen so easily..