A new study published in the December 2019 issue of The Joint Commission Journal on Quality and Patient Safety details a quality improvement project to reduce the risk of single-patient insulin pens.

 Insulin pens are widely used in hospitals because they have multiple safety advantages compared to insulin vials, including a product name and barcode and a dial mechanism for less error-prone dosing. Despite these features, accidental sharing of pens still occurs, putting patients at risk for exposure to HIV, hepatitis B virus or hepatitis C virus.

The study “Is One-Pen, One-Patient Achievable in the Hospital? A Quality Improvement Project to Reduce Risks of Inadvertent Insulin Pen Sharing at a Large Academic Medical Center,” by researchers at Penn Medicine, Philadelphia, involved a multifaceted quality improvement project at one of its academic medical centers to address safety issues of single-patient insulin pens. 

Five root causes for accidental sharing of pens were identified:

• Knowledge gaps and practice variation
• Labels
• Insulin storage and removal process
• Information technology issues including those related to barcode medication administration and the electronic health record
• Insulin administration workflow

Four major interventions to address the root causes were developed and tested:

• Patient-specific bar coding on insulin pens
• Redesign of labels
• Systematic removal of discharged patients’ medications
• Ongoing staff education 

As a result of the interventions, the hospital had a significant increase in the number of days between self-reported adverse events of insulin pen sharing. The most significant decrease occurred after the implementation of patient-specific barcode scanning. There also was a gradual decrease in latent errors found during medication drawer audits, and nursing compliance with patient-specific bar code scanning improved over time.

Of 35 expert recommendations for insulin pen safety, 28 directly affected pen sharing. Eight of these had been implemented prior to this project, and 20 had been implemented by the conclusion.

“Insulin pen use is highly complex in hospital settings where multiple steps provide opportunities for error. To protect patients, all gaps need to be reviewed, and interventions that address major contributing factors are required to ensure safe insulin pen use,” the article concluded.

For more information, visit The Joint Commission Journal on Quality and Patient Safety website.