Improving Patient Safety By Decreasing The Number Of Insulin Pen Injection Errors

Running head: IMPROVING PATIENT SAFETY 1

Improving Patient Safety by Decreasing the Number of Insulin Pen Injection Errors

Name:

Institution:

IMPROVING PATIENT SAFETY 2

Abstract

About six million of those who suffer from diabetes use insulin as a way of controlling their

blood glucose. Therefore, it is not surprising that insulin consistently ranks among the topmost

dispensed medication. While insulin has traditionally been administered through injection using

syringe and vial only, the use of insulin pens has become popular. Insulin pens are supposed to

be used several times, but this use should be restricted to one patient only and a new needle used

for every injection. This is because the patient’s blood could flow back into the cartridge, thereby

heightening the risk of pathogen transmission if used on another patient. One of the most

efficient approaches to preventing this is through the order- and patient-specific barcode

scanning. This entails scanning both the patient and using an order specific, EHR-generated

barcode attached to the insulin injector pen. This paper focuses on the QSEN competency of

patient safety and proposes a similar system to eliminate insulin pen injection errors.

Key words: insulin, pen injection, EHR, barcode scanning, patient safety

IMPROVING PATIENT SAFETY 3

Introduction

Among diabetic patients, an estimated six million use insulin as a way of controlling their

levels of blood glucose (Truong, 2017). In fact, there has been an increase in the use of insulin

together with oral therapy, perhaps because of its introduction during the initial phase of

treatment for individuals with type 2 diabetes. Therefore, it is not surprising that insulin

systematically features among the most dispensed medication. It is worth noting that insulin is

included in the Institute of Safe Medical Practices (ISMP) list of high-alert medications, which

constitutes drugs whose risk of causing considerable harm to patients when administered in error

is extremely high. Insulin has the potential to cause considerable harm to the patient when

administered incorrectly. In this regard, correct insulin administration is of critical importance

because a wrong technique or dosage could cause severe hypoglycemia or hypoglycemic crisis,

requiring visits to the emergency department (ED). Traditionally, insulin has often been

administered through injection using syringe and vial only. While this method is still in use, it is

no longer popular. Today, over 60 percent of insulin users globally use insulin pen devices in the

administration of insulin.

Insulin injector pens were at first developed to assist patients at home to administer their

insulin doses correctly and without difficulty. However, these devices have since found

widespread use in hospitals and clinics, as well. While insulin pens are supposed to be used

several times, this use should be restricted to one patient only and a new needle used for every

injection. Therefore, the use of one insulin pen for multiple patients should be zealously

discouraged because of the potential backflow of blood into the cartridge, thereby heightens the

risk of pathogen transmission in the event the pen is used on multiple patients even when a fresh

needle is used (Paparella, 2015). Some studies have found macrophages, red blood cells,

IMPROVING PATIENT SAFETY 4

epithelial cells, and hemoglobin in an estimated 58 percent of insulin in older insulin pen designs

while in newer designs, an estimated 6 percent of cartridges have been found to be contaminated

(Le Flotch et al., 1998; Sonoki et al., 2001; Herdman et al., 2013).

Errors in the methods used in insulin administration abound even with the improvements

and progression in insulin pen technology. Thousands of patients have received and continue to

receive injections from possibly contaminated pens, usually involving the cross-patient use of

insulin pen devices. Consequently, several agencies and national organizations have issued

recommendations to avert this potentially catastrophic oversight. These include never using pen

injectors for several patients, even with a change of needle; clearly labeling the pen with

patients’ identifying information to make certain that injector pens are restricted to one

individual only; and putting in place policies to address issues related to patient safety in

hospitals and clinics that use insulin pens. Hospital personnel might not realize that skin and

blood cells can contaminate the insulin solution in the pen when the device is in use and that

using a new needle does nothing to mitigate this risk. As part of safe practice, it is important that

whenever multiple patient use is detected, healthcare personnel should promptly inform the

exposed patient and provide appropriate follow-up, which must include testing for blood-borne

pathogens (Paparella, 2015). This paper focuses on the QSEN competency of patient safety

through the elimination of insulin pen injection errors, which can negatively impact the health of

those with diabetes and result in more severe health issues.

Background

Insulin pens injectors (commonly referred to as insulin “pens”) are designed for multiple

use on a single patient using a fresh needle each time an injection is administered. Therefore,

insulin pens should never be employed for several patients because the backflow of blood and

IMPROVING PATIENT SAFETY 5

contamination of insulin cartridge by skin cells could happen after injection, leading to the risk

of blood-borne pathogen transmission (such as hepatitis and HIV) in the event that the pen is

employed for multiple patients, even when a fresh needle is used. Many patients have received

insulin injections from possibly contaminated pens, usually due to unrecognized or improper

sharing of pen devices that have been used previously. Numerous studies have established that

biological material can flow back into the insulin cartridge during insulin administration, thereby

heightening the risk of pathogen transmission in cases where the insulin pen is used on several

patients (Grissinger, 2017). Using a fresh needle does not lessen this risk.

A study by Sonoki et al. (2001) identified hemoglobin in 6 out of the 146 (about 4

percent) of insulin cartridges examined while a study by Herdman et al. (2013) found

contamination in the form of hemoglobin or blood cells in about 6 percent of cartridges in newer

models of spent insulin injector pens. Because insulin pens must never be shared in a hospital, an

important question becomes how the use of such pens for wrong (or multiple) patients occurs in

a hospital setting. An analysis of several studies has identified the contributory factors in

connection with the inappropriate sharing and “wrong-patient” errors. The principal contributory

factors include distraction, inappropriate disposal of insulin pens from previous patients who

have been transferred or discharged, the wrong name of the patient on the pen, putting back the

pen in an incorrect medication storage, time pressure, as well as confusion between hospital

bunkmates. According to the Institute of Safe Medication Practices (2017), even though nurses

are aware that patients should not share pens, barcode scanning systems have often revealed that

nurses frequently take the wrong insulin and insulin pens, and could easily administer these

doses in the absence of an alert.

IMPROVING PATIENT SAFETY 6

In fact, the Institute of Safe Medication Practices (2017) further notes that even in

barcode scans, patients continue to receive insulin from pen injectors for other patients, partly

due to the mix-up of pens for different patients, fetching the wrong patient’s injector pen, and

using injector pens left by one patient on another patient in the same bed and room. Another

common cause is the failure to follow up on “wrong patient” alerts from the barcode scanning

system. Even though the extent of biologic contamination that occurs due to insulin pen injection

errors is thought to be significant enough to occasion the spread of blood-borne pathogens, so

far, no lucid evidence exists of pathogen transmission resulting from shared insulin pen injectors

or the use of insulin pens (inadvertent or otherwise) on the wrong patient. It cannot be

overemphasized that the use of the same insulin pens for multiple patients can lead to adverse

outcomes. In practice, such errors can be averted using various intervention, including involving

patients in their treatment and following up closely on barcode alerts.

Assessment

The author recently attended a quality review meeting at the hospital where she works

because there was an insulin pen injection error that she had been involved. The hospital uses

EPIC Computer Charting in administering medications that require two nurses to verify insulin

before giving the medication. Notwithstanding this strategy to prevent the use of insulin pens on

multiple patients, errors still occurred that were attributable to reasons beyond deficits in

knowledge or erroneous beliefs that using a fresh needle is enough to avert cross-contamination.

The author was the nurse who verified the medication dosage, but she did not verify the name on

the insulin pen. As a result, the pen device that was used to administer insulin to the patient had

been from a previous patient and had been taken from the lock box in the patient's room.

Moreover, the insulin pen barcode itself was scanned instead of the patient's label associated

IMPROVING PATIENT SAFETY 7

with each patient. Consequently, the patient was given the right dosage of one unit of insulin SQ,

although using another patient's insulin pen. This is prohibited at the hospital where the author

works. The hospital does not allow sharing of insulin pens because of the exposure of patients to

blood-borne diseases. Worse still, the patient's insulin pen was from the previous patient who

had been diagnosed with HIV and hepatitis C.

The Proposed Solution

Medication misadventure usually takes place along a series of steps. These steps include

medication prescription, interpretation and verification of the prescription, pharmacy dispensing,

and the administration of the prescription. Studies have identified best practices and safety

measures that ensure the appropriate use of insulin pens and the prevention of ‘wrong patient

pen’ cases. One of these practices is the order- and patient-specific barcode scanning. Because

the hospital already has two nurses to verify insulin using the EPIC Computer Charting system,

the solution that this author proposes entails the use of an order specific, EHR-generated barcode

attached to the insulin injector pen. This will leverage on the existing system by meeting the

current gap using electronic alerts within the current electronic health record (EHR). The benefit

of this solution is that by scanning the patient’s wristband followed by the order-specific

barcode, it will be easier to verify both the appropriateness of the insulin, as well as the identity

of the intended patient. This is unlike the current practice, where the patient’s wristband and the

manufacturer’s barcode are scanned, thereby verifying only the type of insulin and not the right

pen.

With the proposed solution, an alert will display immediately on screen if a nurse scans

an order-specific barcode attached to the wrong insulin pen, thereby preventing further

documentation by the electronic medication administration record (eMAR) system. Using such a

IMPROVING PATIENT SAFETY 8

system, the nurse must then obtain the correct insulin pen. It is worth noting that the proposed

solution is a high leverage strategy to reduce and possibly eliminate the occurrence of “wrong-

pen” errors, and indeed other types of errors in insulin administration. Therefore, to be

successful, the hospital will have to implement a BCMA (barcode medication administration),

utilize an eMAR record, and engage an EHR provider to establish if the design logic that

controls the barcode system can allow for the continuous scanning of order-specific barcodes to

be used with several orders for the same type of insulin. The EHR provider will also need to

establish if the barcode programming can allow for continued use in the event of discontinuation

of the specific order for which the injector pen label was created, but there are other active orders

for the same type of insulin. This capability might be lacking in the current barcode and EHR

system being used by the hospital.

Implementation Plan

Healthcare providers have the responsibility of maintaining patient safety because any

oversight can have dire consequences for the patient. The probability of successfully

reprogramming the evolutionary tendencies of humans is exceedingly small. Instead, it is more

practical to put in place a medication system to support healthcare providers in regular and

recurring functions since these are more susceptible to unintended errors. In supporting medical

personnel, the proposed solution will maximize nurses’ time for other functions, such as the

assessment and treatment of patients, as well as patient interaction. The implementation plan has

been condensed into a series of six successive steps discussed below:

Creation of the Implementation Team and Identifying Project Leadership

The first step towards implementing the proposed solution will entail putting in place an

implementation team, which will include pharmacists, physicians, nurse leaders, administrative

IMPROVING PATIENT SAFETY 9

staff, medical assistants, and compliance office personnel. The most important roles with regard

to the implementation are the project manager, the lead physician, and the lead user. The project

manager will cooperate closely with the system vendor and all personnel to not only ensure that

all stakeholders focus on their respective timelines, but also to track the project progress and

manage any routine issues. The lead physicians will guide the hospital all through the

implementation process and will act as the liaison between the users and administrative and

technical personnel. Conversely, the users of the system will assume the role of the in-house

specialist in the new system and, therefore, will be tasked with configuring the system,

developing standard operating procedures, and creating order sets.

Communicating the Need for Change

Communicating the reasons and goals for change is important to the success of any

project. Thus, project leaders will have to be fully engaged and committed to the success of the

change project. Grasping the need for change constitutes the first step in engendering new

behaviors within the organization. Excellent leadership will be required in ensuring that the goal

and the status of the change project, which seeks to entrench the proposed solution, are well

understood. In this manner, getting down into the particular requirements of the system will be

easier. It should be noted that by specifying the essential functions upfront, project leaders will

minimize the costs associated with amending system requirements during the implementation

phase.

Identifying Hardware Needs

Because the proposed solution will involve EHR-generated barcode attached to the

insulin injector pen, it will be prudent to identify EHR hardware needs for the new system. The

Institute of Medicine has come up with a list of important aspects of an effective EHR system.

IMPROVING PATIENT SAFETY 10

These include health information storage (such as a database server) and a software for managing

the information coming into the EHR (such as the patient’s identity, the required insulin dosage,

and whether the scanned barcode on the pen matches that of the patient) to make certain that they

are addressed appropriately by the nurse or physician. Electronic connectivity and

communication should also permit the system, which links barcode scanners to the EHR system,

to communicate flawlessly over the network.

Configuring the System

The third step in the implementation of the proposed solution will be the configuring of

the new system. This will involve working with the EHR provider to ensure that all security

measures are met. It might also require that the hospital complete a HIPAA risk assessment. The

hospital can also customize the system to optimize workflow by developing a catalog of build

aspects that are external to the system, including computerized order entry (COE), medication

management settings, and patient history settings. It will also be prudent to identify hardware

needs for the proposed system as part of the implementation.

Deciding how to Launch the System: Incremental versus “Big Bang”

The hospital will have the option of implementing the solution to all personnel and

patients straight away and on the same day, an approach that is known as the “big bang,” or turn

on selected functions in an incremental or step-wise approach. The second approach will involve

availing the system to certain departments only and later rolling it out slowly to the other

departments. Nurses will begin to acclimatize to the new system once the unit leaders, nurse

educators, and other members of the project team have decided on the approach to be used in

launching the new system. A comparison between the two implementation approaches is

presented in Table 1 below:

IMPROVING PATIENT SAFETY 11

Table 1: A Comparison between Incremental and “Big Bang” Approaches

Approach

Pros

Cons

Incremental

 Reduced loss of

productivity due to

changes resulting from

the adoption of the

new solution

 The nurses, physicians,

and other hospital staff

can slowly master the

capabilities of the new

system

 Nurses and physicians

must be aware of the

different functions to

be rolled out on

different dates

“Big Bang” or Immediate

Approach

 No confusion among

nurses, physicians, and

administrative staff

because all tasks are

completed

electronically

 Demands considerable

organizational

resources and

tremendous support

from staff

Because this paper focuses on the QSEN competency of patient safety, the immediate approach

to implementing the proposed solution is favored. This is because this approach entails using the

new system for all diabetes patients within the hospital who need to use pen injector devices in

administering their insulin doses. Taking the incremental approach would mean using the new

system according to the number of patients. An example would be to make the system available

for only a few patients upon being rolled out, and gradually increase this number over time.

Training Personnel

The training of personnel is crucial to the success of any EHR and eMAR system.

Therefore, the last step of the implementation of the new solution will be to create a training

IMPROVING PATIENT SAFETY 12

schedule to ensure that all staff members have the requisite skills and knowledge to use the new

system upon being launched.

Conclusion

Traditionally, insulin has often been administered through injection using syringe and

vial only. Today, an estimated 60 percent of insulin users globally use insulin pen devices in the

administration of insulin. While insulin pens are supposed to be used several times, this use

should be restricted to one patient only and a new needle used for every injection. This is

because of the potential backflow of blood and skin cells into the cartridge that heightens the risk

of spread of pathogens if the pen is employed on multiple patients. Even though nurses are aware

that patients should not share pens, barcode scanning systems have often revealed that nurses

frequently take the wrong insulin and could easily administer these doses in the absence of an

alert. The author recently attended a quality review meeting at the hospital where she works

because there was an insulin pen injection error that she had been involved. She failed to verify

the name on the insulin pen and, as a result, the pen device that was used to administer insulin to

the patient had been from the previous patient and was taken from the lock box in the patient's

room. To prevent such “wrong patient” errors while administering insulin to patients using

insulin injector pens, this paper proposes a solution that involves using an order specific, EHR-

generated barcode attached to the insulin injector pen to verify both the appropriateness of the

insulin, as well as the intended patient.

IMPROVING PATIENT SAFETY 13

References

Grissinger, M. (2017). "Wrong patient" insulin pen injections alarmingly frequent even with

barcode scanning. P & T, 42(9), 550-552.

Herdman, M. L., Larck, C., Schliesser, S. H., & Jelic, T. M. (2013). Biological contamination of

insulin pens in a hospital setting. American Journal of Health-System Pharmacy, 70(14),

1244-1248.

Institute of Safe Medication Practices. (2017). ISMP guidelines for optimizing safe subcutaneous

insulin use in adults. Retrieved 10 November 2017 from

http://www.diabetesincontrol.com/wp-content/uploads/2017/05/Insulin-Guidelines-for-

Safety.pdf.

Le Flotch J.-P., Herbreteau, C., Lange, F., & Perlemuter, L. (1998). Biologic material in needles

and cartridges after insulin injection with a pen in diabetic patients. Diabetes Care, 21(9),

1502-1504.

Paparella, S. F. (2015). Insulin pens: Single patient use is mandatory for safety. Journal of

Emergency Nursing, 41(4), 340-342.

Sonoki, K., Yoshinari, M., Iwase, M., Tashiro, K., Iino, K., Wakisaka, M., & Fujishima, M.

(2001). Regurgitation of blood into insulin cartridges in the pen-like injectors. Diabetes

Care, 24(3), 603-604.

Truong, T. H., Nguyen, T. T., Armor, B. L., & Farley, J. R. (2017). Errors in the administration

technique of insulin pen devices: A result of insufficient education. Diabetes Therapy,

8(2), 221-226.

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