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

摘要

Background: The Food and Drug Administration (FDA), Centers for Disease Control and Prevention (CDC), and In-stitute for Safe Medicine Practices (ISMP) have issued warnings regarding the risk of potential transmission of blood-bornediseases if an insulin pen is used for more than one person. Many hospitals continue to use insulin pens due to their benefitsof decreased risk of dosing error and improved work efficiency. Best practices for insulin pen use have been published;however, little is known about how these perform in hospitals.Methods: This article describes a multifaceted quality improvement project to address the safety issues of single-patientinsulin pens. Major interventions included adding patient-specific bar coding on insulin pens, redesign of labels, systematicremoval of discharged patients’ medications, and ongoing staff education.Results: Self-reported events of insulin pen sharing events over 40 months showed a significant increase in the numberof patient-days between events. The significant change occurred after implementation of patient-specific bar code scanning.There was a gradual decrease in latent errors found during medication drawer audits, and nursing compliance with patientspecificbar code scanning improved over time, reaching 90% on the last recorded month. Of 35 expert recommendationsfor insulin pen safety, 28 directly affected pen sharing-8 had been implemented prior to this project, and 20 had beenimplemented by the conclusion.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 toensure safe insulin pen use.