A patient safety alert was issued in 2016 to warn NHS providers of the risk of severe harm and death if an insulin needle and syringe is used to administer insulin withdrawn directly from a pen device or replacement cartridge. This practice should not happen as the strength of insulin in pen devices varies, creating a risk of overdose if the strength is not taken into consideration when determining the volume required.
Overdose of insulin due to abbreviations or incorrect device is now a ‘Never Event’ in the NHS. One of the three scenarios that constitutes an overdose is the withdrawal of insulin from an insulin pen or pen refill and then administering this using a syringe and needle.