PSA Advisories

The Current State of “Wrong Patient” Insulin Pen Injections

Thousands of patients in the United States have received injections from potentially contaminated insulin pens, typically involving inappropriate or unrecognized sharing of a patient’s previously used insulin pen device. Analyst query of the Pennsylvania Patient Safety Reporting System identified 82 reports of potential or actual wrong-patient errors with the use of insulin pen devices in Pennsylvania from 2005 through 2014. Over half (n = 43) of the reports describe actual administration events, 35.4% (n = 29) were close calls, and the remaining 12.2% (n = 10) did not indicate whether or not administration took place. Nearly two-thirds (n = 54) of the 82 events, including 67.4% (n = 29) of the actual administration events, occurred during 2013 or 2014. Despite widespread media coverage, recommendations from national organizations, and application of strategies considered best practices, wrong-patient insulin pen injections continue to occur. Hospitals are encouraged to analyze their own wrong-patient events with the use of insulin pens and examine their current insulin practices as they decide whether to use insulin pens, vials, or a combination of the two. (Pa Patient Saf Advis 2015 Sep;12[3]:110-15.)

Please click here for the complete article on the Pennsylvania Patient Safety Authority’s website.

More Alerts

We recently learned about three cases of accidental spinal injection of tranexamic acid instead of a local anesthetic intended for regional (spinal) anesthesia. Container mix-ups were involved in each case. In one case, a patient scheduled for knee surgery received tranexamic acid instead of
Medication use in the perioperative setting presents unique patient safety challenges compared with other hospital settings. For example, perioperative medication prescribing and administration often bypasses standard safety checks, such as electronic physician order entry with decision support