Insulin Pens: Are your patients safe?

December 17, 2014    |   By: Calevir

A success story from CoxHealth, Springfield, Missouri

Insulin pens were designed for convenience to permit a single person to administer multiple self-injections, using a new needle each time. Many hospitals began using the pens because of their convenience and accuracy. However, reports from several hospitals indicated that the pens were being reused, placing thousands of patients at risk. An alert from the Center for Disease Control in 2009 warned that the pens should be used on a single patient only and are not to be shared between patients. Despite this alert, inappropriate use in hospitals continues, indicating that some healthcare personnel do not adhere to safe practices and may be unaware of the risks to patients.

After reading recommendations from the Institute for Safe Medication Practices in 2013 to consider transitioning away from pens back to vials, CoxHealth initiated a multi-disciplinary team to investigate how the pens were being used at their hospital. The team completed an analysis audit to better understand the risk of vials versus pens, and found that the risk of transitioning back to vials due to dosing errors outweighed the risk for inadvertent sharing of pens. During the initial pen audit, it was identified that only 69% of patients who used insulin pens had all identified safety measures in place. The initial audits indicated that nurses consistently knew to use one pen per patient, but they found unlabeled pens in patients medication drawers and the practice of “borrowing” unused pens from another patient’s medication drawer for efficiency.

Two process improvement opportunities were identified and tracked:

  • Pens with no label or patient identification
  • Multiple pens in a patient’s medication drawer which made it easy to “borrow” an unused pen for another patient

A Failure Modes and Effects Analysis identified causes of the failures, which were further understood using a flowchart.

IMPROVEMENTS
Based on the team’s audit findings and research, CoxHealth implemented the following improvements:

  1. Pharmacy changed the way pens are labeled so a label could not be peeled off for unused pen use on another patient, and to prevent the label from covering the barcode on the pen.
  2. Pharmacy no longer sends a new pen when there is an insulin dose change. Instead, the labels default to “zero”; if a new pen is needed, it is requested by Nursing.
  3. All Novolog orders are treated as STAT orders so the insulin is readily available, decreasing the need for nurses to “borrow” from other patients’ medication drawers.
  4. Decentralized pharmacy technicians audit and monitor the insulin pen process, acting as a resource for nursing staff and assuring STAT insulin orders are quickly processed.
  5. All nursing and pharmacy staff were educated on the improved process, and training was added to the annual credentialing requirements. An on-line module as well as hands-on training were developed in conjunction with a Novolog representative.
  6. Patient Safety prepared an Insulin Pen Poster as a constant reminder for staff.
  7. Insulin pen audits are performed monthly, with plans to move to a quarterly audit when acceptable results are achieved.

The results of the analysis show improved compliance with all pens having a patient label from 77% in February 2013 to 100% in November of 2014. Overall compliance for all safety requirements is at 92%, with the outlier being multiple pens in the patient medication drawers. The goal is to remove the temptation to use an ‘extra’ unused pen in order to administer mealtime insulin on time without having to wait for pharmacy to distribute the pen.

Kudos to CoxHealth for ensuring insulin administration safety for their patients.

For more information contact Susan Houk at 417-269-5431 or [email protected]

Insulin pens were designed for convenience to permit a single person to administer multiple self-injections, using a new needle each time. Many hospitals began using the pens because of their convenience and accuracy. However, reports from several hospitals indicated that the pens were being reused, placing thousands of patients at risk. An alert from the Center for Disease Control in 2009 warned that the pens should be used on a single patient only and are not to be shared between patients. Despite this alert, inappropriate use in hospitals continues, indicating that some healthcare personnel do not adhere to safe practices and may be unaware of the risks to patients.

After reading recommendations from the Institute for Safe Medication Practices in 2013 to consider transitioning away from pens back to vials, CoxHealth initiated a multi-disciplinary team to investigate how the pens were being used at their hospital. The team completed an analysis audit to better understand the risk of vials versus pens, and found that the risk of transitioning back to vials due to dosing errors outweighed the risk for inadvertent sharing of pens. During the initial pen audit, it was identified that only 69% of patients who used insulin pens had all identified safety measures in place. The initial audits indicated that nurses consistently knew to use one pen per patient, but they found unlabeled pens in patients medication drawers and the practice of “borrowing” unused pens from another patient’s medication drawer for efficiency.
Two process improvement opportunities were identified and tracked:
Pens with no label or patient identification
Multiple pens in a patient’s medication drawer which made it easy to “borrow” an unused pen for another patient
A Failure Modes and Effects Analysis identified causes of the failures, which were further understood using a flowchart.
Improvements
Based on the team’s audit findings and research, CoxHealth implemented the following improvements:
Pharmacy changed the way pens are labeled so a label could not be peeled off for unused pen use on another patient, and to prevent the label from covering the barcode on the pen.
Pharmacy no longer sends a new pen when there is an insulin dose change. Instead, the labels default to “zero”; if a new pen is needed, it is requested by Nursing.
All Novolog orders are treated as STAT orders so the insulin is readily available, decreasing the need for nurses to “borrow” from other patients’ medication drawers.
Decentralized pharmacy technicians audit and monitor the insulin pen process, acting as a resource for nursing staff and assuring STAT insulin orders are quickly processed.
All nursing and pharmacy staff were educated on the improved process, and training was added to the annual credentialing requirements. An on-line module as well as hands-on training were developed in conjunction with a Novolog representative.
Patient Safety prepared an Insulin Pen Poster as a constant reminder for staff.
Insulin pen audits are performed monthly, with plans to move to a quarterly audit when acceptable results are achieved.
The results of the analysis show improved compliance with all pens having a patient label from 77% in February 2013 to 100% in November of 2014. Overall compliance for all safety requirements is at 92%, with the outlier being multiple pens in the patient medication drawers. The goal is to remove the temptation to use an ‘extra’ unused pen in order to administer mealtime insulin on time without having to wait for pharmacy to distribute the pen.
Kudos to CoxHealth for ensuring insulin administration safety for their patients.
For more information contact Susan Houk at 417-269-5431 or [email protected]

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