3,100 patients notified of pen reuse.

NurseAdviseERR July 2014
Another hospital has issued notification letters to several thousand patients who received insulin doses that might have come from an insulin pen used for multiple patients. The letter recommended that effected patients be tested for hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) as a precautionary measure (www.ismp.org/sc?id=366). There have been multiple incidents around the US where the possibility of insulin pen reuse involved 1,000 or more patients. There is strong evidence that retrograde travel of blood carrying hemoglobin, red blood cells, and squamous cells into the pen cartridge occurs after injection. Remind practitioners and staff that pen devices should not be used on more than one person even if the needle is changed.

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