More education is needed for diabetic patients after a patient died from incorrectly using an insulin pen, according to a new warning from the Institute for Safe Medication Practices.
More education is needed for diabetic patients after a patient died from incorrectly using an insulin pen, according to a new warning from the Institute for Safe Medication Practices (ISMP).
While ISMP's National Medication Errors Reporting Program has received several reports of patients who failed to remove the inner cover of a standard insulin pen needle prior to attempting to administer the insulin, the latest event resulted in a fatality.
The patient, who had type 1 diabetes and had recently been hospitalized, did not know to remove the standard needle cover from the insulin pen needle prior to administration. “She was unaware that she was using the pen incorrectly and, thus, had not been receiving any of the insulin doses. The patient developed diabetic ketoacidosis and later died,” ISMP wrote in its National Alert Network newsletter.
Many hospitals use insulin pen needles such as Novocone Autocover (Novo Nordisk) and BD Autoshield Duo that automatically re-cover and lock the pen needle once injection has been completed and the needle has been withdrawn from the skin.
However, because standard pen needles and those with an automatic needle shield may look similar, patients may not be aware of the differences, ISMP said. “Both the automatic safety needle and standard needle systems have a larger outer protective cover that, when removed, exposes either a retractable needle shield or a plain inner needle cover.”
As a result, healthcare providers, including pharmacists, need to better educate patients. “Patients using insulin pens with automatic needle retraction devices while hospitalized, but who will be using standard pen needles at home, must be made aware that the standard needle is different,” ISMP said. “It is imperative that removal of BOTH covers is explained to patients during diabetes education.”
ISMP suggested the following tips for preventing the insulin pen mix-up:
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