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Diabetes Disaster Averted #39: Dialing in On Insulin Pens

I recently had a patient whose blood glucose levels were not under control. Her blood sugar was over 400 when she was referred to me and she had started on an insulin pen. Rather than try to change doses I thought I would check out her technique first….

She dialed up her dose correctly, inserted the needle into the demo pillow properly then dialed back down to zero, thinking she was giving the insulin as ordered. When I questioned her about dialing the pen back to zero she told me that was what the nurse taught her at the doctor’s office

When I asked to see her pen it was still full, so she had not been getting her insulin since getting the pen.

Lesson Learned:

Careful instructions on pen use and having the patient do a return demo or two should help prevent this situation.  This patient also left out the 2 unit safety/air shot which could have helped her to realize she wasn’t getting the insulin.  This part of the pen training is sometimes overlooked by HCP’s. Thank goodness this patient came for out-patient education: otherwise, she could have ended up in the hospital.

Shelda Johnson, RN, CDE

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