The Institute for Safe Medication Practices has issued a new alert, based on reports of faulty use of standard insulin pens in the home after exposure while hospitalized to injectors equipped with retractable needle shields. The safety feature, meant to protect hospital staff and prevent needle reuse, automatically recovers and locks the pen needle once an injection has been completed. The insulin pens commonly used by patients at home look much the same in appearance but typically do not have the additional technology. In order to effectively administer the medication with these devices, both the large outer cover and the inner needle cover must be removed first—an extra step that users may not be aware of when switching from the more sophisticated model to a basic one. In one recent incident, for example, a hospitalized patient with type 2 diabetes ultimately developed ketoacidosis and died after her standard insulin pen failed to deliver the medication because she did not know to remove the inner needle cover before administering the injection. To avoid such tragedies, patients should be informed what kind of pen needle they will be using at home and instructed on its proper use. Upon filling prescriptions, meanwhile, community pharmacists should verify that patients understand the proper administration technique. Patients, for their part, should notify their provider if blood glucose levels do not come down after insulin injection. Manufacturers, lastly, should include warnings on instructions and packaging about removing both covers on standard pen needles.