Tuesday , September 25 2018
Home / Resources / Disasters Averted / The Most Common Error Made when Using an Insulin Pen

The Most Common Error Made when Using an Insulin Pen

Jan 14, 2013

This type of error has been sent to us at least 60 times. So as a medical professional you should be aware of this issue when showing a patient how to use an insulin pen.

Our diabetes team had been working with a patient with type 2 diabetes who was using insulin. She has been on an insulin pen for a year, and had received instruction on the pen from the physician’s office upon initiation of the insulin prior to seeing us.

She was very frustrated that her BG values had not come down despite recent increases in her insulin doses.

In one of our group classes, another patient asked about insulin pen technique so I demonstrated how to use an insulin pen. The patient later called our office and reported that she had the answer to why her BG values remained elevated. For a year, she had been dialing the dose on the pen, injecting it into the subcutaneous tissue, then dialing it back to “0.” She had never actually injected the insulin!

I re-educated her on the proper use of a pen, priming, and counting after injection to ensure all insulin had been delivered. The physician has been notified and insulin doses have been decreased. We are confident that the patient’s blood glucose values will now improve.

Lesson Learned:

Never assume your patients know how to inject and use insulin even if they have been on it for a long time. Whenever you have a question as to why a patient’s blood sugars are not improving with an increase in insulin, have them physically demonstrate their technique.

Amy Martin, 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.



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 $50.00. 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.

Copyright © 2012 Diabetes In Control, Inc.

←Previous Diabetes Disaster Averted 
Multiple Safety Checks Missed Resulting in Double-dose Error

Next Diabetes Disaster Averted 
Transcription Error Caught Just in Time

For the complete list of Diabetes Disasters Averted, just follow this link.