Hospital’s Insulin Pen Misuse Leads to Testing of 4,200 Patients

The Institute for Safe Medication Practices performs a watchdog function when it comes to monitoring errors in prescribing and administering drugs throughout the U.S. healthcare system. It recently reported that one hospital has had to test 4,200 patients after learning that they may have received insulin injections from insulin pens previously used on other patients.

The hospital, which is not named in the ISMP report, is now testing affected patients for hepatitis and HIV. While the risk that pathogens for either disease were passed on is considered low, there is fear that illnesses resulting from the re-used pens could emerge later.

ISMP says that “retrograde travel,” where blood enters back into an insulin pen cartridge after an injection, is a concern because the blood can carry infectious agents.
At the hospital in question, a nurse said that she had believed that reusing insulin pens on patients was an acceptable practice, probably as a cost-cutting measure, since it takes multiple injections to exhaust an insulin pen’s reservoir.

The ISMP says that the nurse’s belief is a common one at hospitals, and has not been overcome even with recurrent employee education and onsite monitoring.

For hospitalized diabetes patients, ISMP recommends that they not accept injection from an insulin pen unless their names are on a label attached to the pen. While this precaution may not totally eliminate the risk from re-used pens, it does force hospitals to take an extra step that should help prevent injection errors.