Tips to Improve Insulin Safety

Safely prescribe/order insulin

• Avoid writing orders with trailing zeros.¹³
• correct: 10 units of regular insulin
• incorrect: 10.0 units of regular insulin
• Spell out the word “units” instead of abbreviating with “U” or “u.”¹³
• Use TALLman lettering with look-alike drug names, such as HumuLIN and HumaLOG and NovoLIN and NovoLOG.⁶
• Avoid writing “use as directed.”
• Specify pens or vials on prescriptions to avoid confusion.¹⁶ For example, write the full name of the product to avoid confusion with pens, vials, or cartridges (e.g., Levemir FlexTouch).
• Consider standardized ordering to reduce mistakes and avoid transcription errors.⁵
• Use protocol-driven order sets that incorporate blood glucose monitoring and decision support for inpatients.^1,7
• Examples can be found at ISMP Canada (http://www.ismp-canada.org/insulin/#1=tab3).
• Use our chart, How to Switch Insulin Products, (US subscribers; Canadian subscribers) for insulin conversion tips.

Prevent product mix-ups

• Be aware of potential look-alike, sound-alike mix-ups, (e.g., lispro and Lantus), when ordering and dispensing insulin.
• Put safeguards in place such as storing products in separate locations or using shelf tags to avoid mix-ups when dispensing similar looking pens or vials, or for different strengths of insulin (e.g., U-100, U-200, U-300, U-500).
• Educate patients and prescribers about the differences between the different products as related to onset, duration of action, and intended use. See our charts, Comparison of Insulins, (US subscribers; Canadian subscribers) for specifics.
• Avoid attaching labels to the cap of a pen. If caps are interchangeable between pens, this could lead to mix-ups.
• Encourage patients who use multiple types of insulin to double-check that they are using the right pen or vial prior to administration of every dose.
• For inpatients, use standard concentrations of insulin infusions prepared in the pharmacy.¹
• Ensure that pharmacy technicians are knowledgeable about insulin and potential for serious consequences with errors with our technician tutorials:
• Dispensing Insulin and Other Injectable Diabetes Meds
• Diabetes 101
• Preventing Med Errors

Be aware of factors that can impact blood glucose.

• Watch for meds that might impact blood glucose (e.g., corticosteroids, quinolones).
• If patients are receiving multiple med drips containing dextrose, be mindful of the total dextrose content.
• Recommend blood glucose monitoring to prevent hypoglycemia or hyperglycemia when blood glucose might be affected by meds (i.e., starts, stops, dose changes), illness, changes in nutrition, etc.⁴
• For inpatients, use:
• evidence-based protocols/order sets for glucose monitoring during planned and unplanned interruptions in nutrition.¹
• a “hypoglycemic team” to develop a standardized approach to preventing and detecting hypoglycemia.

Understand special considerations with U-500 insulin

• U-500 is FIVE times as concentrated as U-100 insulins, containing 500 units/mL, instead of 100 units/mL. But it’s NOT just a more concentrated form of regular insulin. Its onset (within 30 minutes) is similar to U-100 insulin and its duration (12 to 24 hours) is similar to NPH insulin.^14,15
• Recommend subcutaneous dosing only. U-500 should not be administered intravenously (IV) or intramuscularly (IM).^14,15
• To prevent mix-ups, include the word “concentrated” on orders for U-500 insulin. For example, “insulin human regular (CONCENTRATED) U-500, 150 units (0.3 mL), inject subcutaneously three times daily before meals.”
• U-500 KwikPens (U-500 Humulin R KwikPen [US]; Entuzity KwikPen [Canada]) available as 3 mL (1,500 units)/pen measure doses in ACTUAL insulin units (doses range from 5 to 300 units/injection using 5 unit increments).^14,15
• Recommend using the dose window, not counting clicks, to draw up an accurate dose.^8,14,15
• The dose indicator should line up with the total dose being drawn up.
• Even numbers are printed on the dial (e.g., 10, 20); odd numbers (e.g., 15, 25) are the line in between each number pair.
• Prime U-500 KwikPens with 5 units of insulin instead of the typical 2 units with other pens.^8,15
• Pens may need to be primed multiple times to remove all of the bubbles.^8,15
• If insulin cannot be seen at the end of the needle after EIGHT tries, replace the needle and prime the new needle.^8,15
• Ensure dexterity issues aren’t a concern, especially with larger doses. The dose button extends as the dose increases.
• Counsel patients or caregivers to ensure understanding of dosing and administration.
• U-500 insulin vials (20 mL [10,000 units]/vial [US only]): Ensure patients are prescribed and use U-500 insulin syringes (calibrated to U-500 insulin with 5-unit increment markings to a maximum of 250 units/syringe) to safely draw up doses.
• Errors can occur with U-100 insulin syringes or tuberculin syringes.² If U-500 syringes are not available follow these tips to reduce the risk of confusion and error:^17,18
• When possible, give preference to tuberculin syringes over U-100 syringes and include the units AND mLs to be injected. Example sig: inject 200 units (0.4 mL) twice daily 30 minutes before breakfast and dinner.
• If U-100 insulin syringes must be used, include the units AND the unit marking to be injected. Example sig:
  inject 200 units (40 unit marking) twice daily 30 minutes before breakfast and dinner.¹⁸
• When possible, avoid switching types of syringes. If switching is necessary, consider marking the amount the patient needs to inject on the syringe.
• In the hospital, draw up U-500 doses in the pharmacy. Or, consider using one U-500 pen per patient.¹

Accurate dosing by patients

• For patients with poor vision and/or dexterity, consider:
• tools such as syringe magnifiers or a device that indicates the correct dose has been drawn up (e.g., Count-a-dose).
• the use of insulin pens instead of vials.
• Improperly mixing suspensions (e.g., Humulin N, Humalog Mix 75/25 [US], Novolin N [US], Novolin ge NPH [Canada]) can lead to over-dosing or under-dosing.
• Vials: educate patients to roll (not shake) gently at least ten times before use.⁹
• Pens: educate patients to roll and tip up and down gently at least ten times each before use.
• Note: not all types of insulin can be mixed in the same syringe. Check product labeling before mixing.
• Advise patients to routinely:
• check expiration dates
• visually inspect insulin to be sure it’s clear (for solutions) or uniformly cloudy (for suspensions), without clumps/particles.

Safe use of insulin pens

• Label insulin pens (not just bags) dispensed to patient-care units for individual patients.¹
• Consider adding tamper-evident seals on pens to identify which ones have been used.
• Use the motto, “one pen, one patient.”^1,10 Pens should only be used for a single patient, even if the needle is changed.^10,11
• Discourage “work-arounds” such as withdrawing doses for multiple patients from a single pen cartridge.
• Advise patients who use more than one pen to double-check that they have the correct pen before administering a dose.
• Review information such as priming and operation of the pen with patients, caregivers, etc. Include steps such as:
• attach the needle
• prime the pen before each dose to expel air bubbles
• dial the dose
• press the button completely and leave the needle in the skin for 5 to 10 seconds to deliver the full dose
• discard the needle
• Train patients/caregivers on proper use. If available, give printed step-by-step instructions (specific to US products):

• Humalog KwikPen: https://uspl.lilly.com/humalog/humalog.html#ug1
• NovoPen Echo: https://www.novo-pi.com/novopenecho.pdf
• Levemir FlexTouch: http://www.med.umich.edu/1libr/PedEndocrine/Diabetes/LevemirFlextouch.pdf
• Lantus SoloSTAR: https://www.lantus.com/-/media/EMS/Conditions/Diabetes/Brands/lantus-final/PDF/lantus-quick-reference-patient-brochure.pdf

• Educate patients not to reuse needles with their pens. Reuse can dull needles and lead to pain. Reuse can also lead to infection.
• Discourage leaving needles on the pen due to increased risk of air bubbles, leaks, or clogging.¹²
• Prescribe insulin quantities in multiples of mLs or units per box of pens, based on how supplied (e.g., 1500 units [15 mL] if there are three U-100 5 mL pens per box). Be sure that the quantity prescribed matches the intended days’ supply.
• Include an Rx for pen needles with prescriptions for pens.

Time insulin doses properly

• Make sure that appropriate and specific times are indicated on orders for insulin. Avoid dosing schedules such as “bid.”
• See our charts, Comparison of Insulins (US subscribers; Canadian subscribers), for usual dosing frequencies.
• Use our algorithms, Initiation and Adjustment of Insulin Regimens for Type 2 Diabetes (US subscribers; Canadian subscribers).
• Use insulin infusion protocols in critical patients.⁴
• Recommend rapid-acting insulin administration with the first bite of a meal.¹
• Consider administering prandial insulin at the end of the meal in patients with variable food intake.¹

Educate about insulin use

• Educate patients about insulin use.
• Review proper injection technique (e.g., skin prep, angle of needle insertion, pinching a skinfold, site rotation).⁹
• Observe the patient administer a dose, with his or her own supplies, to identify errors and improve technique.
• Consider referring patients to a diabetes education program or certified diabetes educator (CDE) including at hospital discharge.⁴ Use the following websites to find a local CDE:
• US: http://www.ncbde.org/find-a-cde/
• Canada: https://systems.cdecb.ca/findCDE
• Educate patients about the signs and symptoms of hypoglycemia, and its management.
• In the US, use CPT code 99211 to bill for insulin teaching provided by a nurse or pharmacist on a separate visit.³
• Participate in education and teaching of other health care professionals who are involved in the use of insulin (e.g., prescribing, compounding, dispensing, administering, monitoring).¹

Store insulin properly

• Avoid storing U-500 insulin in patient care areas.¹
• Label insulin vials and pens with proper storage instructions, including when to refrigerate products and beyond-use dating when products are stored at room temp, if applicable. For specifics use our:
• charts: Comparison of Insulins (US subscribers; Canadian subscribers)
• technician tutorial: Stay Cool: Storing Meds in the Fridge or Freezer
• Remind patients when devices should NOT be stored in the refrigerator, such as in-use insulin pens.
• Store U-500 insulin and U-500 syringes separate from other insulin or syringes to avoid mixups.