Diabetes Disaster Averted #29: Clinic Cartridge Mix-up Cause for Concern
"We recently learned about an error involving Lilly insulin pens. The event happened at a clinic that dispenses insulin pens to patients for use at home. The pen devices were stored on a cabinet shelf while the Lilly HUMALOG insulin cartridges that are used with the pen devices were stored in the refrigerator....
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Several days after dispensing a pen device to a patient, the patient was in the emergency department (ED) with an elevated blood sugar. As part of their evaluation, ED personnel examined the insulin pen device brought in by the patient. After opening the pen to determine if the insulin cartridge was empty or defective, staff found that the pen contained a teaching cartridge filled with saline.
When a teaching cartridge is put in the pen device, you cannot see the drug name or banded colors that differentiate the teaching cartridges from actual insulin cartridges. The Humalog insulin cartridge has red bands on both ends with red lettering whereas the saline cartridge has black bands with black lettering. The manufacturer provides the pens in an unsealed box, which means that a teaching pen with a saline cartridge could accidentally be placed in the box.
Fortunately, the patient received insulin in the ED and was able to return home without any further consequences. The clinic was not sure how the training pen got into their supply.
Lesson Learned:
To improve safety, clinic staff should open every box of pen devices they receive for a visual check, and then recheck each pen before dispensing it to the patient. You can also add a seal using colored tape after inspecting the contents.
Lilly was contacted, and suggestions were made by clinic staff to avoid similar occurrences at other locations, such as supplying the pens in sealed boxes. Staff said they would also like to see different markings on teaching pens and cartridges to help distinguish them. Perhaps a different color could also be used and/or prominent labeling that differentiates teaching devices from insulin-containing devices."
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