Use of insulin pens for inpatient insulin administration is accurate and safe. However, if the pen is used on more than one patient, there is potential risk of infection with pathogens including hepatitis viruses and HIV. Rapid-acting insulin (RAI) is a time-critical medication, both for correctional and nutritional doses. Many hospitals using insulin pens choose to dispense them with a patient specific ID barcode from the pharmacy. This workflow ensures the correct patient ID for scanning, yet it may result in dispensing duplicates and may create time-critical delays. At UCSF, automated dispensing machines (ADM) on adult-units house time-critical medications, including RAI. In this workflow, the RN labels the insulin pen with the patient specific 3D barcode generated on the unit. Prior to insulin pen administration, 3 barcodes must be scanned: 1. Patient armband, 2. Patient label on insulin pen. (NEW) 3. Insulin pen manufacturer (confirms an active order for this type of insulin). The EMR will flash a screen size alert with a red stop sign and a warning if the patient’s armband ID and the pen label’s patient ID do not match. Implemented in 2/2017, this workflow and alert system, for the approximately 18,000 insulin pen SQ injections administered per month has triggered 10-25 alerts per month. As of 11/1/2017, all alerts have stopped the process and the correct patient’s insulin pen was retrieved and administered. Each alert is followed by an investigation. Significant factors contributing to the triggering of an alert involve RNs caring for >1 patient with RAI insulin orders, pens returned to the wrong patient specific cassette in centralized medication rooms, carrying > 1 patient’s insulin pen at a time and opening > 1 patient’s EMR in the patient’s room when scanning. We conclude that pen misuse can be avoided with compliance to our triple scanning system, in conjunction with best practices, while preserving the critical timing of rapid-acting insulin.


H.W. Macmaster: None. A. Maruoka: None. C. San Luis: None. S. Gonzalez: None. R.J. Rushakoff: None.

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