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

Area of Science:

• Healthcare Informatics
• Patient Safety
• Nursing Protocols

Background:

• Insulin is a high-alert medication frequently used for inpatient hyperglycemia.
• Shared insulin pens pose a risk of blood-borne pathogen transmission.
• Wrong-patient insulin pen errors are a concern in healthcare settings.

Purpose of the Study:

• To develop and implement a nursing protocol to improve insulin pen availability and reduce errors.
• To integrate electronic health record (EHR) systems with insulin pen administration workflows.
• To enhance patient safety by preventing wrong-patient insulin pen administrations.

Main Methods:

• A hospitalwide patient-specific bar code label workflow was implemented, integrated with the EHR.
• "Print Label For Insulin Pen" and "Scan Insulin Pen" functions were added to the EHR.
• A "wrong-patient pen alert" system was activated to prevent errors.

Main Results:

• Over 162,000 insulin pen administrations were analyzed from April 2017 to March 2018.
• Monthly insulin pen administration errors ranged from 0.12% to 0.23%.
• 296 near-miss events (0.18%) were successfully prevented.

Conclusions:

• The implemented EHR and insulin pen workflow successfully maintained insulin as a time-critical medication.
• Patient safety was significantly enhanced through these electronic medication administration record system improvements.
• Integrating safety features into EHRs is crucial for maximizing patient safety in medication administration.