Insulin pen users: dial-up then push button


If you have diabetes and take insulin using an insulin pen, you may be one of many who are not using the pen correctly. Many insulin pens have a dial on one end of the pen to "dial-up the dose" (Figure 1, top). That same end has a button that needs to be pushed so the dose can be delivered (Figure 1, bottom).

We recently learned that some individuals have been dialing the dose correctly but then, after inserting the pen's needle under the skin, they dialed the dose back down to zero believing that action would deliver the dose. Instead of dialing-down the dose, they should have pushed the button to deliver the dialed dose of insulin. Without pushing the button, the dose of insulin was never given. 

dial up and push

Obviously, insulin that never reaches the patient is going to result in a high blood sugar (glucose) level. These errors were discovered by the patients' doctors, nurses, or diabetic educators who asked the individuals to demonstrate how they were giving their insulin.

If you use an insulin pen, talk to your doctor, pharmacist, nurse, or diabetic educator about how to use the pen correctly. If a family member or other caregiver gives you your insulin, make sure they understand how to use the device as well.

Created on December 12, 2014

Medication Safety Alerts

FDA Safety Alerts

Show Your Support!

ISMP needs your help to continue our life saving work