Patient Safety Alert: Risk of severe harm and death due to withdrawing insulin form pen devices Alert reference number: NHS/PSA/W/2016/011
JUL 2017

There is a paper from NHS about Patient Safety Alert on the Risk of severe harm and death due to withdrawing insulin from pen devices issued on Nov 16, 2016.


Incidents happen when healthcare staffs use insulin syringes and needles to extract insulin directly from pen devices which contains insulin with a higher strength than 100 units/ml.  This will lead to a significant and potentially fatal overdose as the strength of the insulin on the pen device was not taken into consideration while determining the volume required.  These incidents showed evidence of issues regarding the availability of appropriate safety needles and a lack of adequate training for staff in using insulin pen devices and safety needles in both community and hospital settings; and also a lack of training for patients.


We hope that this sharing can help healthcare providers minimize incidents that might risk patients' lives in the future and drive improvements in safety and clinical quality. Thank you