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Reuse of Insulin Pen for Multiple Patients Risks Transmission of Bloodborne Disease

A US Army hospital publicly announced last week that 2,114 insulin-dependent diabetic patients admitted between August 2007 and January 2009 may be at risk for developing a bloodborne disease because of incorrect procedures used during the administration of insulin using pen devices.

Insulin pens are intended to be used for a single patient. But according to the announcement, although staff changed the pen’s needle between patients, they reused the pen for more than one patient. In addition, an Army-wide investigation found that pens may have also been used incorrectly at a second US facility, affecting 15 patients or less. In our March 27 and May 8, 2008 newsletters, we noted that at least two studies have shown that biological contamination of insulin occurred in up to half of all reused insulin pen cartridges. Air bubbles and pathogenic contaminants can enter the cartridge after injection while the needle is still attached to the pen. Thus, pens are not suitable for multiple patients without risking cross-contamination. FDA also warned about this risk in its Patient Safety News segment on the topic.

Facilities using insulin pens should act immediately and provide education and continuous monitoring to prohibit situations where an individual patient’s pen might be reused for another patient. Please don’t assume that everyone knows not to do this. In one report, a nurse told us that, rather than waiting for pharmacy to dispense a patient’s pen, nurses at her hospital often borrowed a pen from another patient, put on a new disposable needle, and injected a dose of insulin into the second patient using the first patient’s pen. They were anxious to meet patients’ needs for timely insulin administration and had not perceived the risks associated with this practice. Labeling each dispensed pen with the patient’s name may help to reinforce that the product is intended for that patient alone. If institutional safety with pen devices can’t be assured, they shouldn’t be used. We also hope that insulin manufacturers will do everything in their power to educate professionals about the danger of using pens for multiple patients, and that agencies such as The Joint Commission and state health departments will provide oversight to assure patients are not at risk.