From our partners at the Institute for Safe Medication Practices (ISMP): Safe use of insulin pens for inpatients has been called into question once again.
Over 700 patients at a hospital in New York State may have been exposed to HIV, hepatitis B or hepatitis C because of accidental reuse of insulin pens between October 2010 and November 2012. Hospitals that can’t absolutely assure adequate ongoing staff education and safety monitoring should not employ pens for inpatient use. Sterility cannot be maintained simply by affixing a fresh needle on a previously used pen, this practice continues to place patients at great risk. Despite numerous warnings from FDA, CDC, ISMP, and insulin pen manufacturers, evidence continues to mount that this dangerous practice is adversely affecting thousands of patients. The most recent case is similar to other incidents of massive pen reuse in which 2,114 insulin-dependent diabetic patients were affected at a Texas Hospital (see the February 12, 2009 ISMP.org issue) and, in 2011, more than 2,000 patients at a Wisconsin hospital and outpatient clinic were affected.
In between, ISMP has repeatedly issued warnings
and hazard alerts
about the danger of pen sharing. ISMP also cooperated with FDA for a Patient Safety News video on the topic
. Insulin pens can be reusable with replaceable needles and cartridges but studies show they never should be used on more than one patient, even when the needle is changed, due to retrograde travel of blood and subsequent contamination. Insulin pens offer great convenience to patients and may help in avoiding medication errors. However, they were developed for use in ambulatory care, not for hospital use. Resources for improving safety are available from CDC’s One and Only Campaign
and the Safe Injection Practice Coalition
Courtesy of www.ismp.org
Diabetes in Control would like to acknowledge the Institute for Safe Medication Practices’ outstanding work in medication safety, including the above excerpt.
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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