AACE Patient Safety - Editorials

Insulin Pens and Safety

The Institute for Safe Medication Practices (ISMP) released an article recently that highlighted potential safety problems that are being seen in hospitals when they switch the delivery of insulin subcutaneously from insulin that is drawn from multiple-dose vials to insulin pens. The details of the ISMP Medication Safety Alert were included in an FDA Patient Safety News Alert, #78, which is attached. The study is noteworthy on its own, but the implications for all of us are much broader.

The ISMP properly points out that although insulin pens have many potential advantages, including the potential for achieving both greater accuracy and precision of the insulin dose given, there are potential hazards as well.

For starters, needle stick injuries occur because the pen makes it difficult to see the injection site, and some needles do not have needle guards. Some nurses also will deliberately remove the needle guard because they find it cumbersome.

Moreover, the nurse who is not careful may forget that it is not safe to reuse the pen for multiple patients. Biological materials from the first patient may appear in the insulin pen, and then be injected into the next patient. And at time some nurses have held the pen upside down and misread the dose of insulin, giving an incorrect dose.

To summarize, it is not safe for a hospital to switch from insulin vials to insulin pens without putting their nurses through a rigorous program of education, because in real life, many unexpected errors have occurred. It is not enough to merely point out how these devices work and how they are used, it is at least equally important to recognize how humans, even experienced health professionals, can use them improperly and the harm that can result.

But this editorial is not just about making sure that all of the hospital nursing staffs are using these devices properly, but about much broader issues. Are your patients getting adequate education when they are put on an insulin pen? Did they learn what they needed to know? And even more importantly, what are they doing now when they use an insulin pen?

If you do not know the answer, it would be wise to check how they are doing. You may be pleasantly surprised, but on the other hand, you may be appalled by what you find out.
This is just one example of why patient safety issues are so important. We often take for granted far too much about how people, both providers and patients, are doing. For most of us, especially when we are distracted, do not learn flawlessly, nor remember forever. Yet for us to help our patients as much as they need us to, we must cover the last point, the “slip twixt the cup and the lip”, in order to make sure that our patients are getting the educational intake that they need.
Additional Information

FDA Patient Safety News – Potential Problems with Insulin Pens in Hospitals