Dispense A Needle With That Insulin Pen

Last month we highlighted the confusion patients may experience with insulin pen needles with and without automatic needle retraction devices. Failing to dispense insulin pen needles can be just as hazardous. A patient with diabetes visited an endocrinologist at an academic medical center, where she was prescribed Humulin R U-500 (insulin regular concentrate) pens. The patient was instructed to administer 140 units, 3 times a day. The prescription was dispensed by the medical center’s ambulatory pharmacy, where the patient was given the pens but no pen needles. Because she didn’t have any needles for the pens when she got home, she used one of her U-100 syringes to draw her insulin dose from the U-500 insulin pen cartridge, essentially using the pen as a vial. It is possible that she may have measured and administered as much as '140' units (700 units of U-500). Her daughter found her hypotensive and unresponsive and called emergency medical services. When emergency medical technicians arrived, they gave the patient 12.5 grams of 50% dextrose and transported her to the hospital, where she recovered.

Plans are already under way at the medical center to give ambulatory pharmacists authority to prescribe pen needles when insulin pens are dispensed. Build order sets for insulin pens to include prescriptions for the appropriate pen needle. Explore ways to alert pharmacists to make sure the patient has appropriate pen needles. It is critical for nurses, pharmacists, and prescribers to educate patients about the proper use of insulin pen devices and the importance of using the appropriate pen needle with a pen device and of never using the insulin pen cartridge as a vial.
 

Michael J. Gaunt, PharmD, is a medication safety analyst and the editor of ISMP Medication Safety Alert! Community/ Ambulatory Care Edition.