1. 2013 Education

2. Background From a recent ISMP Medication Alert, hospitals have been advised to evaluate their insulin administration techniques and determine which is the safest way to provide insulin to their patients. The issue surfaced after a hospital on the east coast reported that as many as 700 hospital patients may have come into contact with blood borne diseases such as HIV, Hepatitis from the use of one insulin pen among numerous patients.

3. Background That hospital had to contact the patients who possibly received an injection of insulin with a contaminated pen and bring them back to the hospital for testing and possible treatment of those blood borne diseases. This is not the first hospital that has had to do this but hopefully it will be the last. Because of this hospitals across the nation have been evaluating the use of insulin pens versus changing back insulin vials.

4. At Our Hospital After reviewing the pros and cons for both insulin pens and insulin vials it has been determined that we will continue to use insulin pens. To ensure that we are practicing safe preparation and administration of insulin using an insulin pen, we will be providing on-going education on insulin pen safety.

5. Becoming Aware During 2011 and 2012, insulin errors were the number one medication error for nursing and pharmacy here at Cox. During 2011 and 2012, there were 203 reported insulin errors. While most of the errors were discovered prior to reaching the patient it is important to understand the risks that go with insulin administration and what we can do to make insulin delivery safer for our diabetic patients.

6. Insulin Pen Safety Issues that were identified with insulin pens here at Cox were:  Current way of labeling of the pens  Pens that were not labeled with a pharmacy label or patient sticker  Numerous pens per patient  Lack of knowledge on preparation, dose delivery and storing the pens on the nursing units  Knowledge deficit on how to perform an independent double check

7. Labeling of Pens It was identified that the current process of labeling the pens was not efficient. The labels were being placed on insulin pens in places that covered the red tamper tape or over the barcode making the nurse peel it off to open the pen or scan the barcode. If the label had to be removed to open the pen from that point on it would be very difficult to secure the label to the pen. Without the label we cannot 100% know that the pen belongs to the patient.

8. Old Label

9. New Label

10. New label Pharmacy will now be flagging the label on insulin pens with tape, much like the technique used for oral syringes. Remember this label should continue to go on the body of the pen, not the cap. This step will help to assure:  The label will not fall off  The barcode on the pen is not covered and can be scanned  To help get the right pen to the right patient and increase safety  Should help decrease pens without a label that must be wasted

11. Label Changes Pharmacy made the label changes in March. The change should allow the label to be left on at all times and not cover the barcode on the pen. Do not remove the pharmacy label from the pen. All insulin pens without a patient label or patient sticker must be disposed of and NEVER used on a patient.

12. Numerous Pens per Patient Prior to the new labels, whenever there was a dosage change a new label would print and be placed on a new pen then sent to the floor/ unit. The new label could be scanned so the new dose could be documented because the label on the old pen would no longer scan. Even though the old label could not be scanned the barcode on the pen could. This would cause one patient to have multiple pens of the same medication but a new label.

13. Numerous Pens per Patient Pharmacy staff are being educated to not send a new pen with every dose change since identifying this process issue. On the nursing end, if you receive a new pen because there has been a dose change promptly send the pen back for credit. IT IS NOT ACCEPTABLE TO USE AN UNOPENED PEN INTENDED FOR A PATIENT ON ANOTHER PATIENT THAT NEEDS A PEN. To help with this issue the pharmacy are treating the first time Novolog as a STAT so the pens can arrive quicker.

14. Independent Double Check Insulin is a HIGH ALERT medication and requires an independent double check. The independent double check is preformed by two licensed nurses independently and not together. When performing the double check verify the drug, dose, the route and the time with the order or MAR. With insulin it is also required to note the patient’s current blood sugar and CHO consumed. When performing an independent double check also verify that the insulin pen is labeled and belongs to the patient.

15. Insulin Pens in CDU /SDS If a patient in the CDU or SDS requires insulin their process is different from regular inpatient areas. When a patient requires SQ insulin administration the nurse will remove the insulin pen from their omnicell. The insulin pen should immediately be labeled with a patient sticker. Place the patient’s sticker on the blank flag that pharmacy has placed. Please do not put the label on the cap of the pen. The patient’s insulin pen can then be used to administer future insulin doses.

16. Insulin Pens in CDU or SDS When the nurse removes an insulin pen from the omnicell, a reminder message will appear to remind the nurse to write the beyond use date on the pen/ label.  Lantus and Novolog pens expire 28 days after removal from the omnicell.  Levemir pens expire 42 days after removal from the omnicell.  70/30 pen expire 10 days after removal from the omnicell.

17. Expiration Screen

18. Transferring to an Inpatient Area If a patient from CDU or SDS requires an inpatient admission and has been receiving SQ insulin, the insulin pen should be sent to the admitting floor/ unit via the tube system. The CDU/ SDS nurse should verify that the pen is labeled with a patient sticker and that the insulin pen is not expired. The pen can be used through out the hospitalization. The insulin pen should not be put in the patient’s chart and sent with the transporter unless a nurse accompanies the patient for the transfer.

19. Receiving a Patient from CDU/ SDS If the patient you admit from CDU or SDS has been receiving SQ insulin prior to transfer, expect to receive the pen in the tube system and check there before ordering an additional pen. If the pen is labeled with a patient’s sticker the pen can be used for the rest of the hospitalization or until it is empty. If the pen arrives in the patient’s chart but does not have a patient sticker the pen should be disposed of.

20. FYI When insulin pens have to be disposed of because they are not labeled or not sent to the receiving unit, pharmacy will have to dispense another pen. Most insurance companies will only pay for one pen depending on length of stay and dose amount. So the additional pen would be an excess charge that is removed by the audit and compliance team.

21. Key Points Insulin pens should NEVER be used for more than one patient!! ONE PEN, ONE PATIENT. If the pen does not have a patient label or a patient sticker, the pen SHOULD NOT be used and should be disposed of ALWAYS. Do not remove the pharmacy label from the pen. When performing an independent double check verify that the patient label matches the correct patient.

22. Key Points If a patient has an insulin pen that is not empty and receives another one from pharmacy immediately return it to pharmacy. DO NOT use an unopened insulin pen on another patient. Promptly return it to pharmacy. Pharmacy is treating ALL first time Novolog doses as STAT. Pharmacy staff have also been educated to not send a new pen with dose changes.

23. Key Points If a patient in the CDU or SDS requires an inpatient admission, the CDU or SDS nurse will verify there is a patient label on the insulin pen and send it to the admitting floor via the tube system. DO NOT send pen up in the patient’s chart with a transporter.

25. Insulin Pens To ensure that we are safely administering insulin to our patients on-going education will be required. To review insulin pen dose preparation and administration technique you will now need to complete the credentialing at institution.myflexpen.com institution.myflexpen.com