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A component of the Canadian Medication Incident Reporting and Prevention System (CMIRPS).

SafeMedicationUse Newsletter

Insulin Pens: Important Safety Information


With the many types of insulin pens available, knowing how to inject insulin can be confusing. It is important to use your insulin pen the right way. If you don't use the insulin pen correctly, you may not get the right dose. Without the right dose, there can be unwanted effects, such as dangerously high blood sugar levels.

ISMP (in the United States) received a report about a consumer who did not use an insulin pen the right way. The pen had both an outer cover and an inner cover over the needle. The consumer did not realize that there were two covers and removed only the outer cover of the pen needle before trying to inject the insulin. Because the pen was not being used correctly, the consumer did not receive any insulin doses at all. The patient became very sick and later died. For some consumers, even missing a few doses can be harmful.

Figure 2: Example of a standard insulin needle commonly used at home. Both the outer cover and the needle cover must be removed before injection.
Insulin Pen
Figure 1: Example of a pen with a needle shield that automatically retracts upon injection and locks over the needle when withdrawn from the skin.
Insulin Pen has the following advice for consumers who use insulin pens:

  • Talk to a healthcare provider about how to use your insulin pen. Ask the provider to show you how to use the pen. Also ask for step-by-step written instructions, to be sure that you don't miss any details of the process.
  • If you have recently been in the hospital, you may be given a different insulin pen at discharge from the one you were using at home. Talk to your pharmacist before you use the new insulin pen at home.
  • Keep track of your blood sugar levels. You can use a journal or bring your glucometer to show your healthcare provider at every visit.
  • If your blood sugar levels are higher than expected, or there is a sudden change in your levels, check with your healthcare provider to be sure you are using your insulin pen correctly.


Medication safety bulletins contribute to Global Patient Safety Alerts

This newsletter was developed in collaboration with Best Medicines Coalition and Patients for Patient Safety Canada.

Recommendations are shared with healthcare providers, through the ISMP Canada Safety Bulletin, so that changes can be made together.

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