The Institute for Safe Medication Practices (ISMP) National Medication Errors Reporting Program (MERP) has received several reports of patients who failed to remove the inner cover of a standard insulin pen needle prior to attempting to administer the insulin. The latest event resulted in a fatality. A recently hospitalized patient with type 1 diabetes did not know to remove the standard needle cover from the insulin pen needle prior to administration. She was unaware that she was using the pen incorrectly and, thus, had not been receiving any of the insulin doses. The patient developed diabetic ketoacidosis and later died.

Patients using insulin pens with automatic needle retraction devices while hospitalized, but who will be using standard pen needles at home, must be made aware that the standard needle is different. It is imperative that removal of BOTH covers is explained to patients during diabetes education as depicted in this video: www.myclickfine.com/clickfine-overview.html. Prior to injection, the pen should be “primed” using 2 to 3 units of insulin to make certain that the needle is correctly attached and to remove any air bubbles or pockets in the insulin cartridge. This is known as an ‘air shot’ or safety shot, and the patient should see about 2 drops of insulin come out of the needle. If no insulin appears after two or three attempts, the needle should be tightened or changed until a drop of insulin appears. If a patient continues to see no drops, they might have failed to remove the inner needle cover and will likely bypass this step prior to injection.

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