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A Perfect Storm for Error

Jul 15, 2012

Several years ago, I was working for a hospital-based endocrinology practice.

The hospital had recently started using insulin pens. One of our patients who had been using insulin with traditional syringes for quite a while was discharged with the new insulin pens. It is important to note that the safety pen needles were in use in the hospital. With the safety pen needle cover, the cone collapses as the needle is injected protecting the user from a needle stick.

Several issues combined to produce the “perfect storm” for error:

  • This patient did not know that the pen needle covers she would receive from the pharmacy would be different than those used in the hospital and had to be removed.
  • The patient had been hospitalized for acute asthma requiring steroid treatment; thus the deterioration in control was not unexpected.
  • The patient had an obese abdomen in which the end of the pen was easily lost when injecting.
  • Since the patient had been using insulin for years, the practice did not initially consider dosing technique error.

What happened was that for days the patient was dialing up the insulin dose with her new pen, pushing the needle into her abdominal fat, injecting the dose without ever removing the cap. She assumed the pen cover collapsed as she pushed the pen against her fat.

She had an HHA who had visited her while hospitalized and was supporting her in dosing her insulin. Both had believed that the needle covers were the same as in the hospital. In reality, this patient was injecting the insulin into the needle cover and did not get any insulin for more than a week. Previously, I have had some patients dial up the dose, remove the pen needle covers, inject the pen needle and then DIAL the dose back down, in which case no insulin is given and the pen stays filled. Since, with this lady, the insulin dose was injected from the pen into the pen cover, the supply was dwindling as expected.

With sustained glycemic deterioration despite several dose adjustments over the phone, I had the patient come into the office with insulin pens to observe injection. We were all shocked to observe that the patient had not been removing the needle cover. The patient and HHA were just as shocked as we were.

Lest you think this was an isolated incident, several months later, the phone operator directed a call to me from a recently discharged patient who had been started in insulin while hospitalized. He was not our patient. The call was put through as a courtesy as the patient had a question. He reported rapid deterioration in control since leaving the hospital several days earlier. As I was about to direct patient to emergency room, I first inquired about the pen needle cover, etc…. Sure enough, he too thought that the covers on the pharmacy pen needles were collapsing as he injected the insulin. Once he realized that the pharmacy pen needle covers were not safety needle covers and as such had to be removed, he corrected his injection technique and his numbers stabilized.

Lesson Learned:

For patients in hospitals that use safety needles, staff in-services should be provided to educate patients regarding the difference between hospital safety pen needles and the pen needles that will be used at home. Written handouts should be provided to patients with each prescription for insulin pen needles.

Report Medication Errors to ISMP:

Diabetes in Control is partnered with the Institute for Safe Medication Practices (ISMP) to help ensure errors and near-miss events get reported and shared with millions of health care practitioners. The ISMP is a Patient Safety Organization obligated by law to maintain the anonymity of anyone involved, as well as omitting or changing contextual details for that purpose. Help save lives and protect patients and colleagues by confidentially reporting errors to the ISMP.



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Copyright © 2012 Diabetes In Control, Inc.

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