We’ve launched a national investigation looking at administering insulin from a pen device in hospitals.

One in six hospital beds in England are occupied by someone who has diabetes. In 2017 there were 260,000 people with diabetes in the UK who experienced a medication error. In the same year, 58,000 people with diabetes experienced a hypoglycaemic (low blood sugar) event whilst in hospital.

Reference event

We were notified of a patient who was administered an unintentional overdose of concentrated insulin whilst under the care of an acute hospital. The patient received five times the prescribed dose of insulin.

The insulin was withdrawn from an insulin pen device and then administered using an insulin syringe. This method is not compatible with safe administration of insulin.

Safety around withdrawing insulin from devices has previously been recognised in the UK as a risk.

Find out more about the reference event in our interim bulletin.

Investigation summary

This national investigation is looking at factors that compromise safety when health professionals administer concentrated insulin through insulin pen devices.

The investigation will explore the following safety issues:

  • Use of and knowledge of concentrated insulin which is not licensed for use in England.
  • Perceived and actual barriers to self-administration using a pen device in hospital.
  • Design and usability of pen devices and pen needles.
  • Procurement processes across the NHS specifically around the various pen needles for insulin pen devices.
  • Design of environments in which insulin pens and needles are stored in hospitals.

Find out more by reading our interim bulletin.

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