Development and Implementation of a Subcutaneous Insulin Pen Label Bar Code Scanning Protocol to Prevent Wrong-Patient Insulin Pen Errors.

PROBLEM DEFINITION

Insulin, a high-alert medication, is regularly prescribed in the inpatient setting for hyperglycemia and diabetes mellitus. Although convenient, insulin pens carry a risk of blood-borne pathogens if the same pen is used on multiple patients. At the University of California, San Francisco (UCSF), a new nursing protocol for insulin pen administration was developed to ensure that insulin was quickly available and to identify and move to eliminate wrong-patient insulin pen errors. This protocol involved unit-based automated dispensing machines and an electronic health record (EHR)-integrated patient-specific bar code label work flow.

APPROACH

After piloting on three hospital units, this new patient-specific bar code label process was expanded hospitalwide. "Print Label For Insulin Pen" and "Scan Insulin Pen" buttons were programmed into the EHR to enable nurses to print patient-specific bar code labels. In addition, a "wrong-patient pen alert" was activated to prevent wrong-pen insulin pen administration.

OUTCOMES

For the 162,075 inpatient insulin pen administrations during the study period (April 2017-March 2018), monthly errors (rates) ranged from 13 (0.12%) to 36 (0.23%). In total, 296 near-miss events (0.18% of all insulin pen administrations) were observed and prevented.

CONCLUSION

Insulin pen work flow and EHR changes implemented at UCSF enable subcutaneous insulin to remain a time-critical medication and ensure patient safety. The wide adoption of EHRs offers an opportunity to integrate patient safety improvements directly into the electronic medication administration record systems to maximize patient safety.