The ISMP properly points out that although insulin pens have many potential advantages, including the potential for achieving both greater accuracy and precision of the insulin dose given, there are potential hazards as well.
For starters, needle stick injuries occur because the pen makes it difficult to see the injection site, and some needles do not have needle guards. Some nurses also will deliberately remove the needle guard because they find it cumbersome.
Moreover, the nurse who is not careful may forget that it is not safe to reuse the pen for multiple patients. Biological materials from the first patient may appear in the insulin pen, and then be injected into the next patient. And at time some nurses have held the pen upside down and misread the dose of insulin, giving an incorrect dose.
To summarize, it is not safe for a hospital to switch from insulin vials to insulin pens without putting their nurses through a rigorous program of education, because in real life, many unexpected errors have occurred. It is not enough to merely point out how these devices work and how they are used, it is at least equally important to recognize how humans, even experienced health professionals, can use them improperly and the harm that can result.
But this editorial is not just about making sure that all of the hospital nursing staffs are using these devices properly, but about much broader issues. Are your patients getting adequate education when they are put on an insulin pen? Did they learn what they needed to know? And even more importantly, what are they doing now when they use an insulin pen?
FDA Patient Safety News – Potential Problems with Insulin Pens in Hospitals