NHS Improvement has issued a warning against healthcare professionals using insulin syringes and needles to extract insulin directly from pen devices or refill cartridges. This reportedly occurs where staff are unable to safely dispose of the needles attached to pen devices, or because they lack training in use of pen devices, which are designed for patient use.
A total of 56 such incidents were identified in the National Reporting and Learning System between January 2013 and June 2016. Although these were reported as low- or no-harm incidents, the release stresses the potential for “a significant and potentially fatal overdose” owing to staff being unaware of the nonstandard insulin strength to be found in many pen devices.
Organisations are advised to ensure staff competence with insulin pens, as well as access to safe pen needle disposal.
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