Risk of severe harm and death due to withdrawing insulin from pen devices

A patient safety alert has been issued to warn NHS providers of the risk of severe harm and death if an insulin needle and syringe is used to administer insulin withdrawn directly from a pen device or replacement cartridge.

This short video explains that an insulin syringe and needle must not be used to withdraw medication directly from a patient’s insulin pen device. Organisations are asked to ensure staff have access to appropriate equipment and training for administering insulin using these devices.

Patient Safety Alerts are shared rapidly with healthcare providers via the Central Alerting System (CAS). 

About this alert

Patient safety concerns have been identified where healthcare professionals use an insulin syringe and needle to withdraw medication directly from a patient’s insulin pen device. This practice should not happen as the strength of insulin in pen devices varies, creating a risk of overdose if the strength is not taken into consideration when determining the volume required.

Reports suggest this practice has occurred where staff have not had access to equipment for safely disposing of needles attached to pen devices, and/or lack training in the use of insulin pens.

The alert asks providers to ensure staff have access to appropriate equipment and training for administering insulin using a pen device.

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