COMMENTARY

Don't Do It: Sharing Insulin Pens Jeopardizes Patients

Melissa K. Schaefer, MD

Disclosures

February 21, 2012

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Hello. I'm Dr. Melissa Schaefer, and I am a Medical Officer in the Division of Healthcare Quality Promotion at the Centers for Disease Control and Prevention (CDC). I am pleased to speak with you today as part of the CDC Expert Video Commentary Series on Medscape about some key points with respect to the safe use of insulin pens.

Insulin pens are pen-shaped injector devices that contain a reservoir for insulin or an insulin cartridge. Insulin pens are designed to be used multiple times, for a single person, using a new needle for each injection. Increasingly, insulin pens are being used by healthcare personnel to administer insulin to patients in hospitals and other healthcare settings. However, some providers seem to have a dangerous misperception about insulin pens: They believe that because the pen may be used multiple times, for a single person, it is acceptable to use the same pen for multiple patients as long as the needle is changed. This is completely untrue.

If you reuse a pen on another patient, you may be injecting another patient's blood in addition to insulin. Studies have shown that both blood and skin cells can reflux back into cartridges as insulin is administered. Using the same insulin pen for more than 1 patient is equivalent to using the same syringe to administer medication to multiple patients. Providers need to understand that these practices can expose their patients to bloodborne pathogens, including hepatitis viruses and HIV. Changing the needle on the insulin pen or syringe does not make it safe for reuse on additional patients.

Despite numerous warnings, CDC continues to receive reports of insulin pen sharing. We know of instances in which providers were aware that they were sharing pens but did not understand the risks this posed to patients. In other instances, sharing of pens was accidental. Either way, this is an unacceptable and risky practice.

The following infection-control recommendations should be reviewed by all providers to ensure that they are not placing themselves or persons in their care at risk.

  1. Insulin pens are meant for use on a single person only and should never be used for more than 1 person, even when the needle is changed.

  2. Insulin pens should be clearly labeled with the patient's name or other identifying information to ensure that the correct pen is used only on the correct individual.

  3. If use of a pen for more than 1 person is identified, consider this a serious reportable error; exposed patients should be promptly notified and offered appropriate follow-up, including bloodborne pathogen testing.

These recommendations apply to any setting in which insulin pens are used, including hospitals, assisted living or residential care facilities, skilled nursing facilities, and clinics.

Protection from infections, including bloodborne pathogens, is a basic expectation anywhere that healthcare is provided. As is true with syringes, using insulin pens for more than 1 person poses unacceptable risks and should be considered a "never event." Don't do it.

For more information, including information on infection prevention expectations when performing blood glucose monitoring, please see the resources on this page. We appreciate your personal efforts to keep patients healthy and safe.

Thank you.

Web Resources

CDC Clinical Reminder: Insulin Pens Must Never Be Used for More than One Person

CDC Safe Healthcare Blog – Risky pen pals

Infection Prevention during Blood Glucose Monitoring and Insulin Administration

Frequently Asked Questions (FAQs) Regarding Assisted Blood Glucose Monitoring and Insulin Administration

National Quality Forum. Serious Reportable Events In Healthcare -- 2011 Update: A Consensus Report

Melissa Schaefer, MD , is a medical officer in the Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention (CDC). She works on the ambulatory and long-term care team in DHQP. Her efforts focus on infection prevention in ambulatory care settings, with a particular emphasis on ambulatory surgical centers (ASC) and issues related to injection safety and assisted monitoring of blood glucose. Recent work has also included collaboration with the Centers for Medicare & Medicaid Services to develop infection control worksheets evaluating infection control practices in ASCs and hospitals during facility inspections.

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