The Connecticut Hospital Association shared the following incident with the Kentucky Institute for Patient Safety and Quality (KIPSQ), KHA’s Patient Safety Organization, for distribution to its members in the hopes that it will prevent a harm event in hospitals.

On May 16, Griffin Hospital in Derby, Connecticut, announced that during a daily safety huddle (begun as part of the hospital’s participation in their statewide high reliability collaborative), it had identified an issue regarding the use of insulin pens — devices intended to make insulin injections more efficient and accurate. They consist of a cartridge and needles. While needles were never reused, a few staff used the cartridges for more than one patient. Despite changing the needles, there is still slight risk of blood contamination of the pen reservoir or cartridge, which could result in transmission of blood-borne pathogens from the previous patient.

Griffin has used the insulin pens for several years and has identified approximately...