Monitoring errors in patients with low health literacy is crucial


Here are 8 areas of diabetes where pharmacists should be more aware of errors.

Many community pharmacists work with underserved or low health literacy diabetic patients.

Most healthcare organizations track errors, but the data they collect is often part of their performance and quality improvement programs and
are rarely accessible to the public. Recent discussions with certified diabetes educators have identified 8 areas where pharmacists should be more aware of the possibility of error.

1. Injecting insulin after means it should be injected before.

Giving insulin before a meal ensures that its onset matches the absorption of glucose consumed during the meal.1.2 Clinicians use different types of insulin for mealtime doses. Compared to regular insulin, the rapid-acting insulin analogues (RAAs) aspart, glulisine and lispro work within minutes of administration. Patients should administer regular insulin 30-45 minutes before a meal and RAA insulin 5-15 minutes before or immediately after starting to eat. They should not wait to finish eating.1.2

2. Use insulin at mealtimes even when not eating.

Administering insulin without consuming food can lead to uncontrolled blood sugar and unpredictable blood sugar control. Hypoglycemia is a preventable adverse event, and pharmacists should periodically remind patients of this fact.

3. Inject insulin into the front of the arm, possibly intramuscularly, rather than into the subcutaneous tissue at the back of the arm.

Remembering all the details about insulin can be difficult for patients. They should be reminded that the insulin should be injected into the fat just under the skin, not into the muscles, and that the correct injection sites are the buttocks, the backs of the arms, the stomach and the thighs.3.4 These sites have a high fat content. The needle is usually not long enough to reach the muscle, but injecting insulin into the muscle is painful and the insulin will be absorbed more quickly, increasing the risk of low blood sugar.3.4

4. Reusing lancets and needles for insulin and/or glucagon-like peptide-1 agonists.

Results of an international study showed that, on average, users of disposable syringe needles reused needles 3.3 times5 and on average, insulin pens reused 3.6 times. A whopping 26.6% of insulin pen users reused needles more than 5 times.5 Results of a 2021 study in the United States showed that approximately 50% of individuals reuse lancets and needles, with reuse of lancets being more common than reuse of needles.6 Reusing needles reduces co-payments, especially for patients who inject several times a day. But reusing needles for subcutaneous insulin injection is not recommended.7 It may be associated with cutaneous lipodystrophy, infection and more painful punctures, but little evidence is available regarding these adverse events. A 2016 meta-analysis of 25 studies found that injection site infection was studied most often, but needle reuse was not associated with local infection.8 The results showed a statistically significant association between lipohypertrophy and needle reuse, but found the data inconclusive because the studies had been structured very differently. Reuse of needles was also associated with more pain.8

5. Use of expired insulin.

The use of expired insulin is also common.9.10 Sometimes the smallest amount the pharmacy can dispense is more than the patient will use before it expires. The high cost of products sometimes forces patients to choose between using expired drugs or going without them. Also, once used, injectables for diabetes have a limited expiration date, although the manufacturer’s expiration date is still valid. Patients may not know this. Using expired insulin increases the risk of poor glycemic control.11

6. Adjust medication doses without involving the primary care provider.

Although patients can self-adjust some insulins for diabetes, they should not self-adjust all diabetes medications.12 Clinicians often see patients taking medication once a day when the label says twice a day or taking extra doses when they are hyperglycemic at the maximum daily dose. Monitoring refill history and asking patients when they need refills too soon can identify these non-adherence issues.

7. Not scanning the sensor often enough when using Continuous Glucose Monitoring (CGM).

This prevents the provider from interpreting the data and adjusting doses. Higher CGM scan rates were associated with increased time in glycemic target range and decreased hyper and hypoglycemia. Frequent scans also help patients see how carbohydrate intake, exercise, illness, medications, or stress
affect blood sugar.13 Pharmacists should remind patients to scan at the frequency recommended by their primary care physician (PCP). For full data capture, they should scan the sensor at least 3 times a day, 8 hours apart.

8. Testing blood sugar with a glucometer because the PCP said to do so, but without making any significant changes.

Testing for the sake of testing helps no one and wastes money on expensive supplies. Patients need to know the threshold to check blood sugar more often, check ketones, drink plenty of fluids, restrict carbs, and adjust insulin. For example, a patient who has a random reading of 400 mg/dL should retest to verify the reading and take medication if it is part of the medication plan or if the patient has missed a dose. Going for a walk can sometimes reduce reading, as can avoiding food and drinking lots of water.14


Knowing about common mistakes is a wonderful way to prevent them. Asking a few simple questions when patients take refills and emphasizing potentially confusing points, such as expiration dates, is helpful for patients with low literacy.

Jeannette Y.. Wick, MBA, RPh, FACPis the Associate Director of the Office of Pharmacy Professional Development at the University of Connecticut School of Pharmacy at Storrs.


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2. Hartman I. Insulin analogues: impact on treatment success, satisfaction, quality of life and compliance. Clin Med Res. 2008;6(2):54-67. doi:10.3121/cmr.2008.793

3. Fallabel C. Injecting insulin into muscle: do’s and don’ts. Strong diabetes. April 21, 2021. Accessed February 22, 2022.

4. Stewart K. Dos and Don’ts of Insulin Injections. May 5, 2014. Accessed February 22, 2022.

5. De Coninck C, Frid A, Gaspar R, et al. Results and analysis of the survey Questionnaire on the technique of insulin injection 2008-2009. Diabetes J. 2010;2(3):168-179. doi:10.1111/j.1753-0407.2010.00077.x

6. Montoya JM, Thompson BM, Boyle ME, Leighton ME, Cook CB. Patterns of handling and disposal of sharp objects in diabetic patients using insulin. J Diabetes Sci Technol. 2021;15(1):60-66. doi:10.1177/1932296819882926

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8. Zabaleta-Del-Olmo E, Vlacho B, Jodar-Fernández L, et al. Safety of needle reuse for subcutaneous insulin injection: a systematic review and meta-analysis. Int J Nurs Stud. 2016;60:121-132. doi:10.1016/j.ijnurstu.2016.04.010

9. Thomas K. Drugmakers accused of fixing insulin prices. New York Times. January 30, 2017. Accessed February 22, 2022.

10. Picchi A. The rising cost of insulin: “horror stories every day”. CBS News. May 9, 2018. Accessed February 22, 2022.

11. Kelly B. Nursing interventions for people with type 1 diabetes and frequent hypoglycemia. Br J community nurses. 2021;26(11):544-552. doi:10.12968/bjcn.2021.26.11.544

12. Mehta R, Goldenberg R, Katselnik D, Kuritzky L. Practical advice on basal insulin initiation, titration, and switching: a narrative review for primary care. Anne-Med. 2021;53(1):998-1009. doi:10.1080/07853890.2021.1925148

13. Hirsch IB, Nardacci E, Verderese CA. Snapshot continuous glucose monitoring: implications for the use of continuous data in the daily management of diabetes. Diabetes spectrum. 2019;32(4):355-367. doi:10.2337/ds18-0059

14. Blood sugar at 400: what to do, risks and causes. Meal plans for diabetes. Accessed February 22, 2022.


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