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

Summary

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.

Content

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.