SafetyShare® newsletter brought to you by the Premier Safety Institute®
February 25, 2013
Patients at risk with reuse of insulin pen injectors on multiple patients
In honor of Patient Safety Awareness Week, March 3-9, 2013, we are featuring proper use of insulin pen injectors because of ongoing patient safety risks. This fits the
theme – Seven days of awareness and 365 days of commitment.
We are sending this a week ahead in hopes that you will include safe insulin pen use on your agenda for the safety week!
Gina Pugliese, RN MS, editor
Two recent incidents of reuse of insulin pen injectors on multiple patients occurred in January 2013 in two hospitals in New York State that required
contacting more than 3000 patients for HIV, HBV and HCV testing.
Ongoing reports of reuse of insulin pens results in thousands of patient notifications
Ongoing reports of reuse of insulin pens on multiple patients have resulted in thousands of patient notifications, despite warnings from
professional organizations and manufacturers on their proper use.
Infection risk when pen reused on multiple patients
Insulin pen injectors were introduced in 1985 for diabetics to use in the outpatient, community and home settings to give themselves insulin more
conveniently, reduce risk of medication errors and increase compliance. These insulin pen injectors are also being used in the inpatient setting with
increasing frequency and with ongoing reports of misuse. In the inpatient setting, rather than labeling and using these pens for a single patient, as
intended, these pens have been found to be shared among patients with staff changing the needle and reusing them. This reuse exposes subsequent patients to
bloodborne pathogens through cross contamination.
Education has not been enough
How can it be that after more than two decades since insulin pens were introduced we are still seeing these pens being used on multiple patients? It only
takes one individual who does not know that it is unsafe to replace the needle and then use the insulin pen on another patient to put subsequent patients
at risk. We have seen that education, government alerts and staff monitoring
have not eliminated this problem.
Some hospitals prohibiting insulin pens in inpatient setting
Hospitals are evaluating their policies for insulin pen use with some eliminating them altogether in the inpatient setting. In January, the Veterans Health
Administration, for example, issued a
patient safety alert that prohibits the use of multi-dose insulin pen injectors on all patient care units with
a few exceptions, e.g., patients being educated prior to discharge on their
use, part of a research protocol, or when dispensed directly to the patient
as an outpatient prescription
Review your practices and policy
Take this opportunity to review and monitor the injection practices of your staff in all settings where insulin is administered. Include proper glucose
monitoring, insulin administration and proper pen use during orientation and annual educational programs for nursing and pharmacy staff, including agency
and contract personnel. Consider featuring injection safety and other safe injection practices during Patient Safety Awareness Week.
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