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

Summary

The Centers for Disease Control and Prevention (CDC) has become increasingly aware of reports of improper use of insulin pens, which places individuals at risk of infection with pathogens including hepatitis viruses and human immunodeficiency virus (HIV). This notice serves as a reminder that insulin pens must never be used on more than one person.

Background

Insulin pens are pen-shaped injector devices that contain a reservoir for insulin or an insulin cartridge. These devices are designed to permit self-injection and are intended for single-person use. In healthcare settings, these devices are often used by healthcare personnel to administer insulin to patients. Insulin pens are designed to be used multiple times, for a single person, using a new needle for each injection. Insulin pens must never be used for more than one person. Regurgitation of blood into the insulin cartridge can occur after injection [1] creating a risk of bloodborne pathogen transmission if the pen is used for more than one person, even when the needle is changed.

In 2009, in response to reports of improper use of insulin pens in hospitals, the Food and Drug Administration (FDA) issued an alert for healthcare professionals reminding them that insulin pens are meant for use on a single patient only and are not to be shared between patients [2]. In spite of this alert, there have been continuing reports of patients placed at risk through inappropriate reuse and sharing of insulin pens, including an incident in 2011 that required notification of more than 2,000 potentially exposed patients [3]. These events indicate that some healthcare personnel do not adhere to safe practices and may be unaware of the risks these unsafe practices pose to patients.

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Recommendations

Anyone using insulin pens should review the following recommendations to ensure that they are not placing persons in their care at risk for infection.

• Insulin pens containing multiple doses of insulin are meant for use on a single person only, and should never be used for more than one person, even when the needle is changed.
• Insulin pens should be clearly labeled with the person’s name or other identifying information to ensure that the correct pen is used only on the correct individual.
• Hospitals and other facilities should review their policies and educate their staff regarding safe use of insulin pens and similar devices.
• If reuse is identified, exposed persons should be promptly notified and offered appropriate follow-up including bloodborne pathogen testing.

These recommendations apply to any setting where insulin pens are used, including assisted living or residential care facilities, skilled nursing facilities, clinics, health fairs, shelters, detention facilities, senior centers, schools, and camps as well as licensed healthcare facilities. Protection from infections, including bloodborne pathogens, is a basic expectation anywhere healthcare is provided. Use of insulin pens for more than one person, like other forms of syringe reuse [4], imposes unacceptable risks and should be considered a ‘never event’.

See additional information on assuring safe care during blood glucose monitoring and insulin administration.

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References

1. Sonoki K, Yoshinari M, Iwase M, Tashiro K, Iino K, Wakisaka M, Fujishima M. Regurgitation of blood into insulin cartridges in the pen-like injectors. Diabetes Care. 2001;24(3):603-4.
2. Information for healthcare professionals: risk of transmission of blood-borne pathogens from shared use of insulin pens (2009). U.S. Food and Drug Administration Postmarket Drug Safety Information for Patients and Providers.
3. Important Patient Safety Notification (2011). Dean Clinic.
4. Centers for Disease Control and Prevention (CDC) and the Safe Injection Practices Coalition (SIPC).

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