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Use of Insulin Pens

The Centers for Medicare and Medicaid Services (CMS) has recently received reports of the use of insulin pens for more than one patient, with at least one 2011 episode resulting in the need for post-exposure patient notification. These reports indicate that some healthcare personnel do not adhere to safe practices and may be unaware of the risks these unsafe practices pose to patients.

Insulin pens are meant for use by a single patient only. Sharing of insulin pens is essentially the same as sharing needles or syringes, and must be cited, consistent with the applicable provider/supplier specific survey guidance, in the same manner as re-use of needles or syringes.

Insulin pens are pen-shaped injector devices that contain a reservoir for insulin or an insulin cartridge. These devices are designed to permit self-injection and are intended for single-person use. In healthcare settings, these devices are often used by healthcare personnel to administer insulin to patients. Insulin pens are designed to be used multiple times by a single patient, using a new needle for each injection. Insulin pens must never be used for more than one patient.

Regurgitation of blood into the insulin cartridge after injection will create a risk of bloodborne pathogen transmission if the pen is used for more than one patient, even when the needle is changed.

Any provider using insulin pens should review the following recommendations to prevent transmission of bloodborne infections in the patients under their care.

  • Insulin pens containing multiple doses of insulin are meant for single patient use only, and must never be used for more than one person, even when the needle is changed.
  • Insulin pens must be clearly labeled with the patient's name or other identifiers to verify that the correct pen is used on the correct patient.
  • Healthcare facilities should review their policies and procedures and educate their staff regarding safe use of insulin pens.