NHS England publishes report on patient safety concerns linked to passive safety pen needles

November 2023

A recent report* written by the National Patient Safety team at NHS England assessed the delivery of insulin with passive safety pen needles citing issues such as pooled insulin and the potential for under-dosing. The mechanism of delivery using a passive safety needle requires consistent pressure to be applied on contact with the skin and throughout delivery of the medication. If pressure is reduced the safety mechanism deploys and contact with the patient is lost, meaning any undelivered medication will sit either in the device or on the patient’s skin. Early activation of the safety mechanism on passive devices, blocks the insulin from being administered to the patient and is largely caused by a lack of training in how the device must be used. 
The study identifies a theme of incident reports describing observation of pooled insulin during administration, with associated actions taken such as additional blood glucose monitoring to maintain patient safety. Some reports also noted unexpected presentations of high blood glucose values and unforeseen presentations of diabetic ketoacidosis.

While acknowledging that insulin is a critical medicine, the report suggests that active safety needles might be less of a risk due to their mechanism of use and subsequent accurate and assured delivery of insulin. This is especially important where there is limited education and training for insulin delivery and a heavy reliance on a temporary or transient workforce. The article emphasises the need for education and training on both needle types, suggesting a balanced consideration of factors like safety, ease of use, and dosage accuracy when selecting insulin delivery devices. 

Request a copy of the report here

*Jennings, S. (2023) ‘NHS England National Patient Safety Team PSI 115.2022. Summary for NAMDET: Insulin Pen Safety Needles’, National Patient Safety Team Updates, 6(2), pp. 30–31.