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Insulin Pens: Getting the Basics Right

Of all our published Diabetes Disasters Averted, one error in particular keeps showing up: we have received more than 15 cases focused on the correct use of insulin pens. This week we have yet another addressing the importance of assessing a patient’s basic skills when something does not make sense….

I had a 55 year old male patient who had had type 2 diabetes for many years. As his disease progressed he moved from orals to a regime of orals and a QD injection of basal insulin. At that time he came to a diabetes education session and was taught the correct technique for administering insulin via a syringe.

Several years later the patient was placed on prandial bolus insulin. He was given insulin pen samples in the endo office and the medical assistant demonstrated pen use. The patient met with a dietitian (non CDE) and was taught carb counting and the endo provided a carb to insulin ratio. He began taking bolus insulin but his blood sugars and A1C never really improved. The dose became higher and higher and this went on for two years with his A1C staying close to 9%. Finally the patient was told to come see me.

I am an RN CDE working in an outpatient diabetes education program. I assessed the patient and within the first 5 minutes I identified the problem. First I asked him how long a pen lasted. He told me he read the directions (this man was a lawyer) and knew to throw out anything remaining after 28 days and open a new pen. Then I asked him to show me how he used the pen: every detail should be looked at. He primed the pen with 2 units and injected the needle into his abdomen correctly, but then proceeded to dial the dose back to zero. He injected ZERO insulin! For two years this man had an A1C of 9% and had thrown out two years’ worth of insulin.

Lesson Learned:

Diabetes Education by a CDE is invaluable to patients with diabetes, and a complete assessment of all basic skills is essential both for effective treatment and cost control.

Barbara Nadolny RN, CDE

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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