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?”.







McIntosh BA, Trettin KW. Beyond insulin pen sharing: hospital systems issues. Topics in Patient Safety 2013; 13(2): 2-3






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