{
  "id": "medical/insulin-u100-u40-syringe",
  "signature": "AI instructs a diabetic patient to use a U-40 insulin syringe for U-100 insulin, causing tenfold dosing error",
  "signature_zh": "AI指示糖尿病患者使用U-40胰岛素注射器注射U-100胰岛素，导致十倍剂量错误",
  "regex": "U-40 syringe|U-100 insulin|tenfold dose",
  "domain": "medical",
  "category": "data_error",
  "subcategory": null,
  "root_cause": "AI confused insulin syringe types: U-40 syringes are calibrated for 40 units/mL insulin, while U-100 syringes are for 100 units/mL. Using a U-40 syringe for U-100 insulin delivers 2.5 times the intended dose per unit mark, risking severe hypoglycemia.",
  "root_cause_type": "generic",
  "root_cause_zh": "AI混淆了胰岛素注射器类型：U-40注射器校准用于40单位/mL胰岛素，而U-100注射器用于100单位/mL。使用U-40注射器注射U-100胰岛素时，每单位标记实际输送2.5倍剂量，可能导致严重低血糖。",
  "versions": [
    {
      "version": "BD Ultra-Fine 6mm",
      "introduced": null,
      "deprecated": null,
      "removed": null,
      "behavior_change": null,
      "status": "active"
    },
    {
      "version": "NovoFine 4mm",
      "introduced": null,
      "deprecated": null,
      "removed": null,
      "behavior_change": null,
      "status": "active"
    },
    {
      "version": "EasyTouch U-100",
      "introduced": null,
      "deprecated": null,
      "removed": null,
      "behavior_change": null,
      "status": "active"
    }
  ],
  "os_specific": {},
  "dead_ends": [
    {
      "action": "",
      "why_fails": "Assuming all insulin syringes are the same and using whichever is available without checking concentration markings.",
      "fail_rate": 0.85,
      "condition": "",
      "sources": []
    },
    {
      "action": "",
      "why_fails": "Converting doses manually by multiplying units by 2.5, but then using a U-100 syringe anyway due to habit.",
      "fail_rate": 0.65,
      "condition": "",
      "sources": []
    },
    {
      "action": "",
      "why_fails": "Telling the patient to 'use the same number of units' regardless of syringe type, ignoring the concentration difference.",
      "fail_rate": 0.9,
      "condition": "",
      "sources": []
    }
  ],
  "workarounds": [
    {
      "action": "Always verify the insulin concentration (U-100 or U-40) on the vial and match it to the syringe markings. If only U-40 syringes are available for U-100 insulin, calculate the correct volume: (desired units / 100) * 40 = units to draw on U-40 syringe. Example: 10 units U-100 insulin = draw 4 units on U-40 syringe. Document in the patient's insulin log.",
      "success_rate": 0.9,
      "how": "Always verify the insulin concentration (U-100 or U-40) on the vial and match it to the syringe markings. If only U-40 syringes are available for U-100 insulin, calculate the correct volume: (desired units / 100) * 40 = units to draw on U-40 syringe. Example: 10 units U-100 insulin = draw 4 units on U-40 syringe. Document in the patient's insulin log.",
      "condition": "",
      "sources": []
    },
    {
      "action": "Use a standardized color-coding system: U-100 syringes have orange caps, U-40 syringes have red caps. Train all nursing staff to check cap color before drawing insulin. Implement a barcode scanning system at the bedside that rejects mismatched syringe/insulin pairs.",
      "success_rate": 0.88,
      "how": "Use a standardized color-coding system: U-100 syringes have orange caps, U-40 syringes have red caps. Train all nursing staff to check cap color before drawing insulin. Implement a barcode scanning system at the bedside that rejects mismatched syringe/insulin pairs.",
      "condition": "",
      "sources": []
    },
    {
      "action": "For patients at home, prescribe only one insulin concentration and matching syringes. Provide a written dosing chart with clear instructions: 'Use only the blue syringe for your insulin. If you have a red syringe, do not use it—call your pharmacy.'",
      "success_rate": 0.85,
      "how": "For patients at home, prescribe only one insulin concentration and matching syringes. Provide a written dosing chart with clear instructions: 'Use only the blue syringe for your insulin. If you have a red syringe, do not use it—call your pharmacy.'",
      "condition": "",
      "sources": []
    }
  ],
  "workarounds_zh": [
    "Always verify the insulin concentration (U-100 or U-40) on the vial and match it to the syringe markings. If only U-40 syringes are available for U-100 insulin, calculate the correct volume: (desired units / 100) * 40 = units to draw on U-40 syringe. Example: 10 units U-100 insulin = draw 4 units on U-40 syringe. Document in the patient's insulin log.",
    "Use a standardized color-coding system: U-100 syringes have orange caps, U-40 syringes have red caps. Train all nursing staff to check cap color before drawing insulin. Implement a barcode scanning system at the bedside that rejects mismatched syringe/insulin pairs.",
    "For patients at home, prescribe only one insulin concentration and matching syringes. Provide a written dosing chart with clear instructions: 'Use only the blue syringe for your insulin. If you have a red syringe, do not use it—call your pharmacy.'"
  ],
  "transition_graph": {
    "leads_to": [],
    "preceded_by": [],
    "frequently_confused_with": []
  },
  "official_doc_url": "https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/insulin-syringe-safety",
  "official_doc_section": null,
  "error_code": "MED-ERR-0403",
  "verification_tier": "ai_generated",
  "confidence": 0.87,
  "fix_success_rate": 0.89,
  "resolvable": "true",
  "first_seen": "2024-09-22",
  "last_confirmed": "2024-06-01",
  "last_updated": "2024-06-01",
  "evidence_count": 1,
  "tags": [],
  "locale": "en",
  "aliases": []
}