A new study published in the December 2019 issue of The Joint Commission Journal on Quality and Patient Safety details a quality improvement project by researchers at Penn Medicine, Philadelphia, USA, 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.
Five root causes for accidental sharing of pens were identified:
- knowledge gaps and practice variation
- 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.