Jennifer Gold

Jennifer Gold

Friday, 02 March 2012 20:20

Insulin Pen Safety

sanofiInsulin pens have become a popular way for diabetics to give themselves insulin. Insulin pens are available for multiple insulin types. However, as with any technology, pens can be misused leading to medication errors and inaccurate administration of insulin. Although an insulin pen is easy to use, certain precautions must be taken to assure proper use.

Below is a list of safety tips to keep in mind when using an insulin pen:

1. Do not share your insulin pen with anyone:

Insulin pens should never be used for more than one person. Using insulin pens on more than one person puts people at risk for infection with blood-borne pathogens such as hepatitis viruses and HIV, which causes AIDS, the agency warns. Infection can occur even if an insulin pen's needle is changed. We are aware of this happening in hospitals, where, for example, a nurse may not realize the risk.  Pen needles are changed in between patients but the very same pen is used for multiple patients! This is dangerous because even if the needle is changed, it's still possible for insulin in the pen to become contaminated. Then, when subsequent patients are injected, there's a danger of passing along harmful bacterial or virus.

2. Do not withdraw insulin from an insulin pen cartridge

Using insulin pens as "mini" insulin vials, by drawing up insulin into an insulin syringe, can lead to inaccurate dose measurement the next time the insulin pen is used for dose delivery. The reason for this is related to air entering the pen unintentionally, interfering with the proper mechanics of the pen.

3. Do not leave an open needle attached to an insulin pen

Leaving an insulin needle attached to an insulin pen can lead to unintentional air entering into the insulin pen. If unintentional air enters into the insulin pen, it can contribute to air bubbles accumulating within the insulin and pen and ultimately improper dosing of insulin.  It could also lead to insulin contamination.

4. Insulin pens must be stored at room temperature

Storing your insulin pen in extreme temperatures can lead to changes in the concentration of the pen's insulin.  For example, going from a cold place to a hot place causes your insulin to expand. As insulin expands, it could leak out of the needle passageway, and change the concentration of the insulin. This change in concentration will change the strength of your insulin and may lead to an inadvertent overdose.

5. Proper insulin pen mixing

Every time you use a pen containing NPH (neutral protamine Hagedorn) insulin, it must be rolled between the palms 10 times and then tipped up and down 10 times to mix the insulin properly. The same mixing process is needed for pens with mixtures of NPH insulin and Regular insulin (e.g., 70/30, 75/25, etc.). The insulin should look uniformly cloudy or milky after mixing. If there are clumps floating in the insulin, or white particles stuck to the bottom or sides of the pen giving it a frosted look, don't use it. Otherwise, large doses of insulin can come out during the first injection, leaving less in the pen for injections that follow.

6. The way that insulin pen needles are used may differ

The introduction of insulin pens has risen sharply in recent years and allows patients to inject their insulin in a convenient, discrete and relatively easy to use way. The needles used with most pens are interchangeable and are sold separately. But the way they are used may differ between needle brands. Consumers must be aware because using different and unfamiliar insulin needles can cause an error with your treatment.

For example, patients who are familiar with the NovoFine Autocover must remove a needle shield to inject. Then after injection the needle is withdrawn and automatically covers itself so it cannot be used again. But a pen needle that’s available from BD actually requires that two covers be removed (see figures 1 and 2). If you don’t remove the second cover no insulin will be injected.

Novofine.figure 1and2

Patients who use Autocover devices and then switch to standard pen needles must be educated about the need to remove both caps. Removing the gray cap is an extra step that is not required with the NovoFine Autocover needles.

Errors have also occurred with the BD AutoShield Duo pen needles which resulted in failure to deliver insulin. The BD AutoShield Duo pen needle is a safety pen BD auto shieldneedle with shields on both ends of the needle to prevent needlestick exposure during injection and disposal. The shield closest to the patient retracts when the pen and the needle are pressed against the patient’s skin. Afterwards, the shield slides back over the needle, locks into place, and a red indicator becomes visible (figure 1). If the pen is not pressed hard enough (and the white shield is not flush with the skin), the cover will not retract enough resulting in no insulin delivery. Failure to delivery insulin can also occur if the user injects the insulin on an angle that does not allow the retraction mechanism to work properly. Current insulin deliver recommendations note that the pen needle must be injected into the skin at a 90 degree angle, with no skin fold pinch for 4-5mm needles, or with a skinfold pinch for longer needles. Proper demonstration of the BD AutoShield Duo pen needle can be viewed here

7. Using your pen correctly

If you are using an insulin pen for the first time, or recently switched to a new insulin pen, errors can occur when dialing the correct dose.

Example 1

A patient accidently injected too much insulin when she accidently over dialed her insulin pen. The patient using a NovoLog FlexPen gave herself 46 units of NovoLog, not 6 units as prescribed. In error, the patient read the numbers to the right of the dose indicator window not within the window.

                                                  dosing window2

Example 2

A Lantus Solostar pen was prescribed for a patient who only had prior experience administering Lantus from vials using insulin syringes. The patient was not counseled before using the pen and assumed he understood how to use it correctly. However, he misunderstood how the insulin pen worked and accidently administered 225 units of Lantus instead of 75 units.


The error was related to a minor difference in how this particular insulin pen works. The Solostar insulin pen looks like a syringe, or other pen devices. Normally during an injection of insulin the syringe plunger moves all the way to where the needle attaches to the syringe. However, the Solostar pen is not designed to deliver the entire amount of insulin in the reservoir. Therefore, the plunger only moves partially, resting on a reservoir scale that shows the remaining quantity of Lantus in the pen. The patient, who expected the plunger to move like a typical syringe, didn’t notice the subtle movement and repeated the injection three times, delivering 75 units each time.

If you are new to using an insulin pen, always demonstrate to a health care professional how you will measure and administer the dose.

Example 3

Our organization is aware of at least two cases in which improper injection technique led to elevated blood sugars. In both of these cases, ongoing elevated blood sugars led the healthcare provider to investigate the insulin injection technique. After direct observation of the individual injecting the insulin, a crucial error was detected. In both incidences the person injecting insulin correctly dialed up to the prescribed amount of insulin units using the Lantus Solostar (insulin glargine) insulin pen. The person then properly completed the next step and injected the needle into the skin. However, instead of pushing the purple button at the end of the pen to inject the insulin they twisted the dial back down to zero. By dialing back down to the zero, they had believed the twisting mechanism was injecting the insulin. The Lantus Solostar insulin pen is designed to be twisted "up or down" until the user has established the correct amount of insulin to inject. But the button must be pushed to inject the insulin. Both patients in this example had in fact not been receiving any insulin as a result of this error.

insulin pen dial error

The ability to dial up and down on the insulin pen is not just unique to the SoloStar pen. Other insulin pens also have this feature. If you or a family member is using an unfamiliar insulin pen, be sure to first demonstrate to your healthcare provider how you will be using it.

Grapefruit juice can be part of a healthful diet—most of the time. It has vitamin C and potassium—substances your body needs to work properly.

Thursday, 01 March 2012 15:32

Getting your prescription from your doctor

isc getprescriptionfromdocKnowing what type of insulin you are taking is important to ensure you have been given the correct insulin product by the pharmacist. Errors can happen when the doctor is prescribing insulin, when the pharmacy is dispensing insulin or when the nurse, patient or caregiver adminsiters it. One reason this can happen is because there are so many different insulin products available, and some even have similar names. For example, there's Humalog and Humulin and Novolog and Novolin. The insulin safety resource center will give examples of how mix-up's can happen in the prescription or dispensing phase of your treatment and ways you can best assure that corrections are made.

Getting your prescription

The discussion regarding the type of insulin you will take and how often you will require it, starts with a conversation between you and your healthcare provider and diabetes educator, so it's important to pay attention and read all written materials. Each time you visit your doctor, even if you do not expect to change your insulin type, listen closely to the discussion.

Once a medical professional has prescribed insulin, he/she will give you a prescription or send an electronic one to your pharmacy. The prescription will indicate what type of insulin the pharmacist should give you, the dosage you should take, and when you will need to take it. If an electronic prescription is sent, request a duplicate copy for your records. This way, if the wrong insulin is given to you at the pharmacy, you will be able to pick up the mistake by comparing the prescription copy to the container label.

If a written prescription is given to you at the doctor's office, make sure you can interpret the handwriting prior to leaving the office. Confirm the name of the insulin, the dosage, and how often you should take it. Document this for your records, prior to dropping off the prescription at the pharmacy.

Friday, 17 February 2012 21:40

Insulin and your lifestyle

isc foodexerciseFactors such as diet, exercise, alcohol use, and illness can affect your blood sugar.  This makes using insulin more complicated. It is important to think about how changes in diet, exercise, alcohol use, and illness may affect the amount of insulin needed to control your blood sugar.

Insulin lowers blood sugar levels. If something increases your blood sugar, you may need more insulin. It is important to talk to your doctor and pharmacist about changes in your diet, exercise, and alcohol use, and any illnesses that you experience. When people feel sick, they often do not eat very much. This means you may not need as much insulin. If you eat more, you may need more insulin. If you exercise more, you may need less insulin. If you drink more alcohol, this may cause your blood sugar to lower.

isc patientpharmacistYour doctor and pharmacist will discuss steps you need to follow to maintain good blood sugar levels. Your doctor and pharmacist will also discuss how often you will need to check your blood sugar.  Be sure to ask for guidance on how to keep good blood sugar levels and ask how often and when you should check your blood sugar.

Friday, 17 February 2012 21:37

What can go wrong?

Sometimes your blood sugar may get too low or too high.

Low blood sugar can be very dangerous.

To prevent dangerous low blood sugar, here are some important tips:

  • Check your blood sugar often.  Talk to your doctor about how often and what time of day to create your own schedule.
  • Watch out for clues
    • Low blood sugar clues include: irritability, shaky hands, being tired, confusion, headache, heart racing, sweating, pale skin, feeling nervous, cold hands and feet, mood swings, crying spells, depression.
    • Usually, blood sugar is too low if less than 70 (mg/dL).
  • Make sure friends and family also know the clues for low blood sugar. When your blood sugar gets too low, you may be too confused to remember what to do.  It's important that friends and family know when you need help fixing low blood sugar.


 If your blood sugar is less than 70 (mg/dL), OR if you have clues of low blood sugar (see above), take action!


  • Drink a glass of orange juice.
  • Drink a glass of regular soft drink or soda (NOT DIET soda).
  • Eat jelly or jam (NOT SUGAR-FREE jelly)
  • Eat candy (NOT SUGAR-FREE candy)
  • Eat 3 sugar pills.


High Blood Sugar

High blood sugar can be very dangerous also. It may take a long time for you to notice the bad effects of high blood sugar, or you may start to feel sick right away.


  • Emergency: If not treated with diet, exercise, and medicine, high blood sugar can lead to "diabetic coma" and death.
  • Long-Term Disability: If not treated with diet, exercise, and medicine, high blood sugar can lead to heart disease, kidney disease, worsening vision, blindness, loss of feeling in hands and feet, impaired healing of cuts and wounds, tingling and damaged nerves, change in bowel movements and constipation. 

To prevent dangerous high blood sugar, here are some important tips:

  • Check your blood sugar often. Talk to your doctor about how often and what time of day to create your own schedule.
  • Watch out for clues.
    • HIgh blood sugar clues include:
      • Drowsy, sleepy, tired
      • Flushed skin
      • Fruit-like breath odor
      • Frequent urination
      • Dry mouth, Dry skin
      • Loss of appetite, Stomach Ache, Nausea, Vomiting
      • Trouble breathing (rapid and deep)
      • Increased blood sugar level
      • Usually, blood sugar is too high if greater than ______ (mg/dL).
  • Make sure friends and family also know the clues for high blood sugar. When your blood sugar gets too high, you may be too confused to remember what to do.  It's important that friends and family know when you need help fixing high blood sugar.

If your blood sugar is greater than ______ (mg/dL), OR if you have clues of high blood sugar (see above), take action!


  • Call your doctor or pharmacist.
  • Develop an action plan for high blood sugar. This includes knowing how much extra insulin to take based on the blood sugar number.
Monday, 06 February 2012 19:29

Report a Medication Error

Thank you for reporting your error or medication safety concern to ISMP and Please answer the questions as completely and accurately as possible. Your answers will help us to better understand the type of errors that are happening, where and why they are happening, and how to help those people being affected.


Wednesday, 25 January 2012 20:24

Test Feature article

Monday, 23 January 2012 22:43

U-500 Insulin Errors

img vial syringeHumulin R is the brand name for Eli Lilly's recombinant human regular insulin. The usual version of Humulin R is U-100 and contains 100 units of insulin activity per 1 milliliter of fluid. But there's also a rarely-used version called U-500. The U-500 insulin is 5 times more potent than U-100 insulin. U-500 insulin contains 500 units of insulin activity per 1 milliliter of fluid. People may need to use U-500 if their diabetes is not well-controlled with U-100. The U-500 version should be used only for patients requiring doses above 200 units a day.

Important information about U-500 insulin

Since the use of U-500 insulin is not as common as the use of U-100 insulin, some health professionals may not be aware of it. This by itself increases the chance of dispensing errors.

The main problem with U-500 insulin is the risk of a mix-up between the insulin U-100 and insulin U-500 versions. If this occurs, it can result in very dangerous low blood sugar or very high blood sugar. A mix-up between the two insulin concentrations may occur if doctors or pharmacists select the wrong concentration (for example, selecting the U-500 regular insulin from computer screen instead of U-100). Sometimes the two concentrations appear one line apart on the computer screen, which sets up the possibility of selection errors. Depending on the screen size, the prescriber may see only the first few words of the product listing, so the drug concentration is not seen. Prescribers may assume the patient needs U-100 and may not even look for the concentration on the screen.

A mix-up may also occur if U-100 insulin and U-500 insulin are stored next to each other at the pharmacy, in the hospital or even in your home. Although the colors of the vials are different, if someone is not aware to look out for the concentration on the vials, the vials could be confused for one another.

U-500 insulin syringe

As of November 2016, a new syringe to administer concentrated Humulin R U-500 (insulin regular) has been made available from the manufacturer, BD. The syringe measures U-500 insulin doses ranging from 25 units to 250 units in 5-unit segments. Prior to the release of the U-500 syringe, it was recommended to use a U-100 syringe or tuberculin syringe to administer U-500 insulin. But dosing errors frequently occurred to patients who drew doses from a vial into a U-100 or tuberculin syringe. Every unit on the U-100 syringe scale is equal to 5 units of U-500 insulin. So, a dose measuring “40” units in a U-100 syringe is really 200 units of U-500 insulin. With a tuberculin syringe, the U-500 insulin dose has to be measured in mL, not units. Both situations have led to serious insulin dosing errors.

Now that a U-500 syringe is available, a U-100 syringe or tuberculin syringe should no longer be used to administer U-500 insulin in healthcare facilities or in the home.

Humulin R U-500 is also available in a prefilled pen, which also measures the concentrated insulin in 5-unit segments. With the Humulin R U-500 KwikPen, and now with the U-500 insulin syringe, the actual dose of U-500 insulin prescribed is the actual dose that is measured in the syringe or dialed with the pen. The updated information for physicians who prescribe Humulin R U-500 now requires all prescriptions for the U-500 insulin vials to be accompanied by prescriptions for the new U-500 insulin syringes. The updated information also recommends that healthcare providers:

  • Instruct patients who use vials of U-500 to use only a U-500 insulin syringe
  • Teach patients how to correctly draw the prescribed dose into the U-500 insulin syringe
  • Confirm that the patient has understood the directions If you are uncertain how to use the new syringe, ask your pharmacist, doctor, or office nurse.

If you are uncertain how to use the new syringe, ask your pharmacist, doctor, or office nurse.

Other Recommendations

Individuals who use insulin must be aware of the concentration and insulin type that you normally use. If you see U-500 on the label when you are supposed to be getting U-100, or if the opposite is true, make sure you question your pharmacist or doctor before taking it.

Also, if another individual in your home also uses insulin that is not the same concentration as yours, store the insulin in different areas. This way you will not inadvertently grab the wrong vial.

If you are to be hospitalized and you use U-500 insulin, be sure to clarify this with the medical staff. It is recommended to bring whichever syringe you use at home to the hospital and demonstrate where you normally draw up your insulin to.

Monday, 23 January 2012 22:26

Insulin safety during a hospitalization

If you need to be hospitalized

isc patientinhospIf you are someone who requires insulin, one of the most important things you can do to stay safe is to have an emergency plan in the event you become ill and need to be hospitalized. In preparing for such an emergency, it's important to take into consideration that you may be too ill to speak for yourself at this time. Therefore, you should always designate another individual who can assist in this process, as needed.

If you are hospitalized, or admitted for any emergent situation, it will be very important for you to tell your doctor and nurse the type of insulin you take, what dose and how you are taking insulin. You should carry an updated list of all medications you take with you at all times. Ideally, it is safest to bring your medications and insulin delivery system into the hospital to prevent any misunderstandings.

It will also be helpful to inform the health care team of your recent blood sugar readings. However, keep in mind, your usual insulin requirement may change with possible illness or emergent care. Be prepared for potential changes in your insulin regimen, which may be needed during your condition and as determined by your doctor.

During your hospitalization or for emergency care, you (or whomever you have designated) will need to pay close attention to your care. Here are some additional tips to avoid errors with your insulin during hospitalization:

  • Be sure the nurse confirms your identity with two identifiers before any insulin injection. For example, calling you by your first name and checking your arm band. Never accept an insulin injection without the nurse checking you identification band or scanning it if the hospital uses bar coding. Your identification band must always be legible.
  • Have the nurse confirm the type and dose of insulin prior to injection. Also request to visualize the syringe to confirm the amount of units in the syringe.
  • Keep accurate documentation of your blood sugar results. This can serve as a double check in the event a nurse either brings you insulin you did not need, or forgot to administer insulin you did need. Keeping documentation of your blood sugar results can also protect you from getting your roommate's dose instead of yours.
  • If the hospital is using an insulin pen, be sure a label is affixed to the pen with only your name. Insulin pens must never be used for more than one patient. Ask the nurse about this.
  • Keep in mind that some hospitals allow and even encourage patients who are experienced in using insulin at home to self administer their own insulin while hospitalized. If you are comfortable doing this, it is good opportunity for you to maintain control of your own insulin and ensure you are receiving your insulin in a timely manner.
  • If you have special equipment you use to take your insulin, such as a pen or a pump, never assume others will know how to use it. Always try to go over instructions for use with a nurse before surgery or hospitalization. Teach a family member or friend how to use the equipment in case you are too sick or unable to explain it.  
  • During hospitalizations, there may be procedures when you are required not to eat anything. If this occurs, your insulin will likely need to be adjusted or held. Unfortunately, there have been instances when nursing staff have continued insulin injections in error, despite a patient not eating. 
Monday, 23 January 2012 22:21

Insulin safety in your home

Staying safe with insulin in your home: avoiding an insulin mix-up

Mistakes with insulin can happen at home. In fact, people who have been using insulin for many years may be more likely to make a mistake. The more often you perform a task, the more you may do so without acting carefully. For example, if you always keep your long-acting insulin on your bedside table and accidentally switch it with your short-acting insulin, you could mistakenly grab the incorrect insulin thinking it was your long-acting insulin. If you do not carefully read the label, you can inject too much of the short acting form and cause a low blood sugar.

Below are some tips to help avoid an insulin mix-up in your home:

After opening an insulin vial, throw out the carton:

  • Storing insulin vials in the original cardboard carton after the packages have been opened can lead to a mix-up.
  • This happens if you replace the vial into the wrong carton.
  • By eliminating storage of vials in their cartions, the chance of error is eliminated.

If you are using more than one type of insulin, consider using two different insulin devices to inject your insulin.

  • For instance, use a vial and a needle/syringe for your long-acting insulin and an insulin pen for your rapid-acting insulin.
  • If you are unable to use different devices, then consider making each vial, pen, or cartridge look different by putting a rubber band around one type of insulin.
  • You can also use colored stickers to help differentiate the insulin.

Do not ever assume you are using the correct insulin based solely on what it looks like or where it is stored.

  • Some people may think that fast-acting insulin is the only insulin that's a clear liquid. But that's not true. For example, insulin glargine (Lantus) is a clear, 24-hour insulin.
  • Likewise, not all intermediate- or long-acting insulins are cloudy. For example, some pre-mixed combinations of intermediate- and rapid-acting insulins are cloudy.
  • Never rely only on the container or label color to identify your insulin. The label color can be used as a guide to identify insulin but should never be used by itself. In some cases, different types of insulin may have similar label colors. Always look carefully at the label and read it before using any insulin. Differentiate any similiar looking insulin products (e.g. place a rubber band around one type of insulin).

ALWAYS read the label before using your insulin

  • Insulin that is usually stored in one location can be accidently switched by accident or by another person. If you use your insulin based on where it is stored (e.g. butter compartment in refrigerator) and inject it without reading the label carefully, the wrong insulin and dose might be used.