What’s New in the Patient Safety World
April 2013
More Tips on
Insulin Pen Safety
Our February 26,
2013 Patient Safety Tip of the Week “Insulin
Pen Re-Use Incidents: How Do You Monitor Alerts?” highlighted the
occurrence of insulin pens being used on multiple patients, potentially causing
cross-contamination of patients with blood-borne pathogens. The focus of our
column was as much on how organizations are made aware of unsafe practices
discovered elsewhere as it was on the insulin pens themselves. We did provide
some recommendations and referred readers to several articles by ISMP.
Both ISMP and the VA
Health System have discouraged use of insulin pens (or multi-dose pen injectors
for other drugs).
Since then the VA
Health System has done a nice job summarizing many other issues that can arise
when using insulin pens on inpatients (McIntosh 2013).
This has some very practical examples of other system problems that may pertain
to insulin pens and recommendations for hospitals continuing to use them on
inpatient units.
For example, they
note that several factors may result in improper dosing. The “tip and roll”
method may result in incomplete mixing of the insulin suspension, resulting in
inaccurate doses. Failure to “prime” the pen correctly may result in lower than
intended doses. The pen’s dose display may be read upside down during
administration, potentially leading to incorrect doses. Other technical factors
that might lead to incorrect dosing are failure to leave the pen in place for
the required time, unintentionally lifting the pen from the injection site due
to difficulty pressing the pen button, or thinking the a full dose was not
given because a wet spot (from priming) or not recognizing the plunger movement
is gradual, leading to potentially re-dosing the patient.
They also discuss
issues related to needle attachment and disposal and the risks of needle stick
injuries to staff. They note several reasons why adding labeling to pen barrel
is difficult and note that the lack of a tamper-evident cap might lead staff to
think the pen had not been used and return it to pharmacy stock.
Read the McIntosh
article. It has many good recommendations you’ll need to add to your
educational and inservicing programs for nurses and pharmacists and practical
recommendations for system changes you’ll need if you continue to stock insulin
pens for inpatient use. And read the references in our February 26, 2013
Patient Safety Tip of the Week “Insulin
Pen Re-Use Incidents: How Do You Monitor Alerts?”.
References:
McIntosh BA, Trettin KW. Beyond insulin pen sharing: hospital systems issues. Topics in Patient Safety 2013; 13(2): 2-3
http://www.patientsafety.gov/TIPS/Docs/TIPS_MarApr13.pdf
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