Home / Resources / Disasters Averted / Too Common Insulin Pen Error

Too Common Insulin Pen Error

Nov 4, 2013

A patient who was new to insulin therapy and her husband were coached on how to use an insulin pen. The patient and her husband decided that he would give her the injections and the patient’s glucose results were fine. After a few weeks, the patient decided to begin self-injecting. However, her glucose levels were increasing at every clinic visit. Because of the continued high glucose, the CDE nurse was asked to observe the patient inject….

The patient put on the pen needle, dialed the dose, pushed the needle into the skin and then “undialed” the dose and removed the needle. The reason for increasing glucose was that the patient was not actually injecting any insulin. After a review of proper injection technique, the patient was able to inject demonstrating good technique and her glucose levels improved dramatically.

Lesson Learned:

Each patient who is new to injections or new to injection devices such as an insulin pen should be able to demonstrate how they inject with the device.

Judy F. RD, LD, CDE

Copyright © 2013 Diabetes In Control, Inc.


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 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. 

←Previous Diabetes Disaster Averted 
Safety Needles Cause Confusion

Next Diabetes Disaster Averted 
The Power and Dangers of Advertising

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