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ISMP: 4,200 Need Testing after Pen Misuse

Apr 13, 2014

From the Institute for Safe Medication Practices: Once again, a US hospital must contend with the fact that thousands of the hospital’s patients may have received an insulin injection from an insulin pen previously used for another patient. In this recent event, patients are being notified of possible transmission of blood-borne pathogens and being told they should be tested for hepatitis and human immunodeficiency virus (HIV), although the risk is low. No actual cases of disease transmission have been tied to any of the previous “outbreaks” we’ve published.

However, there is strong evidence that retrograde travel of blood carrying hemoglobin, red blood cells, and squamous cells into the pen cartridge occurs after injection. So it won’t be surprising if transmission is eventually documented. In this latest case, apparently one of the nurses at the hospital said she believed that reusing insulin pen reservoirs on multiple patients was an acceptable practice. This problem is well known and not easily overcome with employee education and ongoing monitoring. Patients should be educated to not accept their insulin injection from an insulin pen unless they see their name on an attached label.

To learn more about the use of insulin pens in hospitals, a medication safety fellow at Purdue University is conducting a survey to assess the prevalence of insulin pen utilization in the inpatient setting and to identify best practices to mitigate risks associated with pen utilization. The survey can be found at: http://purdue.qualtrics.com/SE/?SID=SV_dptFAqHbczBwGJD. It should only take 5-7 minutes to complete, and all responses are anonymous. Your input is greatly appreciated.

Diabetes in Control would like to acknowledge the Institute for Safe Medication Practices’ outstanding work in medication safety, including the above excerpt. For more information on this issue as well as other important safety issues, please visit ISMP.org.

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.



And if you have a “Diabetes Disaster Averted” story, please also send it in separately to Diabetes In Control. If we use it you will receive a Visa Gift Card worth $25.00. Click here to let us know the details. (You can use your name or remain anonymous if you prefer.) Please note that ISMP is not associated with this Gift Card promotion.