NHS England releases patient safety concerns report
A recent report from the NHS England National Patient Safety team looked into delivering insulin with passive safety pen needles, after an incident where a patient with Type 1 diabetes developed diabetic ketoacidosis (DKA).
Over a three-year review from 2019 to 2022, a pattern emerged in incident reports describing how pooled insulin was observed during administration. Actions taken included additional blood glucose monitoring to ensure patient safety. Some reports highlighted unexpected high blood glucose readings and cases of diabetic ketoacidosis (DKA) that were not anticipated. These reports suggest that the use of passive safety pen needles may have contributed to these outcomes, since pooled insulin often went unnoticed at the time.
The delivery method with a passive safety needle requires steady and consistent pressure on the skin during the entire injection. If that pressure is interrupted, the safety mechanism is triggered and loses contact with the patient, so any medication that wasn’t delivered either stays inside the device or ends up on the patient’s skin. Early activation of the safety mechanism on passive devices can prevent insulin from reaching the patient and is usually due to insufficient training in correct device use.
There are now alternative safety pen needles for insulin pens that use an active safety mechanism. These active safety needle designs use an approach for insulin delivery similar to standard pen needles. The user needs to manually activate the safety feature to keep themselves safe and ensure proper disposal of the needle.
Unifine SafeControl is an active safety pen needle developed to help healthcare professionals (HCPs) feel confident that they are delivering the full medication dose while also staying protected from needlestick injuries (NSIs). In a clinical study* conducted in 2020, 98% of participants agreed that they felt in control of dose delivery using the SafeControl active safety pen needle. It features an active safety mechanism that works with a manual push tab, giving the HCP complete control, and covers both ends of the needle after the injection is given to help prevent NSIs. The device is built to provide a balance between safety and control throughout the injection, so those providing critical care can have peace of mind and ensure their patients get the right dose.
Both passive and active safety pen needles for insulin are available, and proper education and training are required for their use. Where there are limits to providing in-depth education and training for insulin administration, or when there is a heavy reliance on temporary or rotating staff, using an active safety device may be considered to be less risky for accurate insulin delivery.¹ It’s always important to balance all factors when choosing the best drug delivery device, in terms of safety, ease of use, simplicity, and accurate dosing.