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

摘要

Problem Definition: Insulin, a high-alert medication, is regularly prescribed in the inpatient setting for hyperglycemiaand diabetes mellitus. Although convenient, insulin pens carry a risk of blood-borne pathogens if the same pen is used on multiplepatients. At the University of California, San Francisco (UCSF), a new nursing protocol for insulin pen administrationwas developed to ensure that insulin was quickly available and to identify and move to eliminate wrong-patient insulin penerrors. This protocol involved unit-based automated dispensing machines and an electronic health record (EHR)–integratedpatient-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 toprint patient-specific bar code labels. In addition, a “wrong-patient pen alert”was activated to prevent wrong-pen insulinpen 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 penadministrations) were observed and prevented.Conclusion: Insulin pen work flow and EHR changes implemented at UCSF enable subcutaneous insulin to remain atime-critical medication and ensure patient safety. The wide adoption of EHRs offers an opportunity to integrate patientsafety improvements directly into the electronic medication administration record systems to maximize patient safety.