Peson holding an  insulin injection pen.
Engaging Staff in Solving Safety Issues
​After a health system experienced multiple events in which a patient received an insulin injection with another patient’s pen, with no improvements following root cause analysis and process changes, the safety team published an article in their patient safety newsletter soliciting ideas from staff. Suggestions included storing insulin pens differently and using patient-specific barcoding, and one employee informed them about an insulin pen best practice assessment tool that was developed by the American Society of Health-System Pharmacists (ASHP). Through this article, the team also connected with a hospital that had successfully implemented patient-specific barcoding using the same electronic health record system.

Following an assessment with the ASHP tool and a nurse survey on insulin pen best practices (the results of which were also shared in the patient safety newsletter), a new process was developed that includes pharmacy validation of the correct insulin and patient-specific barcoding, which prevents nurses from administering insulin if the barcodes on the pen and the patient do not match—with another hard stop in place if the manufacturer barcode is mistakenly scanned. The team continues to refine this process as new issues arise and reviews literature to identify opportunities for improvement, and nurses report that they feel better protected from making a medication error and feel that they are keeping their patients safe.​