NHS England: Insulin pen safety engineered needle devices (SENDs) (26 January 2026)

Summary

This case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.

Content

The National Patient Safety Team identified an issue related to delivery of insulin via insulin pen safety engineered needle devices (SENDs). There are both active and passive SENDs available for insulin pens, which have different mechanisms of use.

A recorded incident described a type 1 diabetic developing diabetic ketoacidosis (DKA) where no precipitating factors were identified other than potentially the method of insulin administration. A review of incident data revealed a theme of insulin ‘pooling’ on the skin following administration. This may occur when the needle of a passive SEND retracts during administration, due to releasing pressure too early so insulin sits on the skin. Reports describe patients developing DKA or hyperglycaemia due to delayed recognition of suboptimal insulin administration technique via some insulin pens.

The insight from the review was shared with TREND for their  ‘Injection Technique Matters’ resource and The Royal College of Nursing for RCN Sharp Safety Guidance. Findings were shared with the National Association of Medical Device Educators and Trainers (NAMDET) members via an article in their MDET journal to expand awareness that both passive and active insulin pen SENDs require education and training for use. The findings were also shared with clinical procurement specialists recommending that user education and training requirements are essential considerations when selecting either active or passive insulin pen SENDs, focussing on the additional needs of the temporary or transient workforce.