Ask the Experts: Safe Use of Insulin Pens in Hospitals

Transcription

1 Ask the Experts: Safe Use of Insulin Pens in Hospitals Live Webinar Wednesday, November 12, :00 p.m. 3:00 p.m. EST On-demand Activity Live webinar recorded and archived to be watched at your convenience Available after January 30, 2015 Planned and conducted by ASHP Advantage Supported by an educational grant from Novo Nordisk Inc.

2 Activity Overview Ask the Experts: Safe Use of Insulin Pens in Hospitals Recent reports of sharing of insulin pens in health settings have made insulin pen safety an important priority in hospitals. In this educational activity, ways of identifying potential or actual safety risks related to insulin pen use in individual hospitals will be presented. The faculty will also review selected strategies for making process changes to help ensure the safe and appropriate use of insulin pens in the hospital. The content for this activity is based on questions raised by participants in a recent educational symposium on this topic. Learning Objectives At the conclusion of this application-based educational activity, participants should be able to Evaluate processes within a hospital to identify potential safety risks associated with the use of insulin pen delivery systems. Develop a plan for ensuring best practices in the use of insulin pen delivery systems in hospitals. Continuing Education Accreditation The American Society of Health-System Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. This activity provides 1.0 hour (0.1 CEU no partial credit) of continuing pharmacy education credit (ACPE activity # L05-P for the live activity and ACPE activity # H05-P for the on-demand activity). Participants will process CPE credit online at with the option of printing a CE certificate. CPE credit will be reported directly to CPE Monitor. Per ACPE, CPE credit must be claimed no later than 60 days from the date of a live activity or completion of a home study activity. Webinar Information Visit to find Webinar registration link Group viewing information and technical requirements Instructions for processing CPE credit online 2

3 Activity Faculty Ask the Experts: Safe Use of Insulin Pens in Hospitals Christine A. Lesch, Pharm.D., BCPS, is Clinical Pharmacy Manager in the neurological intensive care unit at NewYork-Presbyterian (NYP) Hospital at Columbia University Medical Center in New York. She also serves as a preceptor in critical care for the hospital s postgraduate year 1 (PGY1) pharmacy practice residency program, as well as for the PGY2 critical care residency program. In addition, she is Affiliate Assistant Clinical Professor at St. Johns University in New York. Dr. Lesch earned her Bachelor of Science in pharmacy and her Doctor of Pharmacy degrees from the University of Minnesota College of Pharmacy in Minneapolis. She completed a drug information residency accredited by the American Society of Health-System Pharmacists at Roche Laboratories and an infectious disease fellowship at the University of Illinois at Chicago. She is a board-certified pharmacotherapy specialist. Dr. Lesch s responsibilities at NYP include serving as Co-Secretary of the Inpatient Glycemic Management Task Force and Co-Chair of the ICU Insulin Task Force. Her research and practice interests include glycemic management, fever control in neurological injury, refractory status-epilepticus, hyponatremia, and management of coagulopathies with concentrated factors. Dr. Lesch is a member of the pharmacy committee with the Neurocritical Care Society. Within the Clinical Pharmacy and Pharmacology Section of the Society of Critical Care Medicine, she is a member of the research committee and contributor for Critical Care Pharmacotherapy Literature Update, the section s monthly newsletter. Dr. Lesch is also a member of the American College of Clinical Pharmacy and New York State Council of Health System Pharmacists. She has co-authored several book chapters and peer-reviewed articles and regularly makes presentations at national meetings. Mark F. Lutz, Pharm.D., CPPS Drug Information Specialist Beaumont Hospital Royal Oak, Michigan Mark F. Lutz, Pharm.D., CPPS, is Drug Information Specialist at Beaumont Hospital in Royal Oak, Michigan. At this site, he serves as preceptor for the drug information and medication safety rotations in the postgraduate year 1 (PGY1) residency. He is also preceptor for the medication safety learning experience for the PGY2 residencies in pharmacy administration and critical care. In addition, Dr. Lutz serves as adjunct faculty for three colleges of pharmacy in Michigan: University of Michigan, Ferris State University, and Wayne State University. Dr. Lutz earned his Doctor of Pharmacy degree from University of Michigan College of Pharmacy in Ann Arbor and completed a PGY1 residency accredited by the American Society of Health-System Pharmacists (ASHP) at William Beaumont Hospital. He is a board-certified professional in patient safety through the Certification Board for Professionals in Patient Safety. Within the three-hospital Beaumont Health System, Dr. Lutz is involved in several committees and initiatives related to his practice interests of medication safety, drug formulary management, and decision support. He has taken the lead role in a multidisciplinary evaluation of inpatient insulin pen safety and implementation of system safety improvements. He also is a patient safety first responder on the patient safety response team. Dr. Lutz is a member of ASHP, Michigan Pharmacists Association, and Michigan Society of Health-System Pharmacists (MSHP). He currently serves on the MSHP Pharmacy Technology and Informatics Task Force. 3

4 Disclosure Statement Ask the Experts: Safe Use of Insulin Pens in Hospitals In accordance with the Accreditation Council for Continuing Medical Education s Standards for Commercial Support and the Accreditation Council for Pharmacy Education s Guidelines for Standards for Commercial Support, ASHP Advantage requires that all individuals involved in the development of activity content disclose their relevant financial relationships. A commercial interest is any entity producing, marketing, re selling, or distributing health care goods or services consumed by, or used on, patients. A person has a relevant financial relationship if the individual or his or her spouse/partner has a financial relationship (e.g., employee, consultant, research grant recipient, speakers bureau, or stockholder) in any amount occurring in the last 12 months with a commercial interest whose products or services may be discussed in the educational activity content over which the individual has control. The existence of these relationships is provided for the information of participants and should not be assumed to have an adverse impact on presentations. All faculty and planners for ASHP Advantage education activities are qualified and selected by ASHP Advantage and required to disclose any relevant financial relationships with commercial interests. ASHP Advantage identifies and resolves conflicts of interest prior to an individual s participation in development of content for an educational activity. Stuart T. Haines, Pharm.D., BCPS, BCACP, Planner, declares that he has served as a consultant for Sanofi USA and has divested himself of this relationship. All other faculty and planners report no financial relationships relevant to this activity. Additional Educational Opportunities and Resources On demand activity, Ensuring the Safe Use of Insulin Pens in the Hospital: Role of the Pharmacist (1 hour CPE) Discussion guide (1 hour CPE) Resource center: Compilation of guidelines, articles, and useful web sites Tool kit: Sample policies and procedures, assessment tools, and educational resources Web based version of this activity for colleagues who missed today s webinar (1 hour CPE, available after January 30, 2015) 4

5 Disclosures Ask the Experts: Safe Use of Insulin Pens in Hospitals Stuart T. Haines, Pharm.D., BCPS, BCACP, Planner, declares that he has served as a consultant for Sanofi USA and has divested himself of this relationship Mark F. Lutz, Pharm.D., CPPS Drug Information Specialist Beaumont Hospital Royal Oak, Michigan Christine A. Lesch, Pharm.D., BCPS Clinical Pharmacy Manager, Critical Care NewYork-Presbyterian Hospital Columbia University Medical Center New York, New York All other faculty and planners report no financial relationships relevant to this activity Learning Objectives At the conclusion of this educational activity, participants should be able to Evaluate processes within a hospital to identify potential safety risks associated with use of insulin pen delivery systems Develop a plan for ensuring best practices in the use of insulin pen delivery systems in hospitals Webinar 1 Recap: Safe Use of Insulin Pens in the Hospital In the inpatient setting: Use of insulin for hyperglycemia management in accordance with best practice guidelines can reduce morbidity and mortality Insulin pen and vial/syringe use are both associated with benefits and limitations Pharmacists can help ensure insulin pen safety Webinar 1 Recap: Safe Use of Insulin Pens in the Hospital Advantages Dose accuracy Satisfaction Convenience Ease of administration Concerns Wrong administration technique errors Infection transmission risk Insulin Pen Wrong Technique Errors Improper priming (2-unit air shot ) Improper suspension mixing Use as a multidose vial Misinterpretation of wet spot on skin Priming residual? Partial dose? 5

6 Insulin Pen Infection Transmission Risk Patient risk Potential biologic contamination of pen cartridge HIV, hepatitis B, hepatitis C Use in wrong patient Nurse risk Needlestick during injection Failure to hold at 90 angle may pierce patient, then fingers of person giving injection Difficult visualization may contribute Automatic needle safety covers help prevent needlestick after injection HIV = human immunodeficiency virus Key Resource Education On-demand activities and discussion guide Resource center External resources Articles and guidelines Tool kit Sample documents Outcome measures Case Vignette Anywhere Medical Center is a 600-bed tertiary-care, academic hospital providing inpatient and ambulatory services to adults and children Insulin provided in pens, vials, pre-drawn syringes After a recent inpatient error involving insulin administration from a wrong patient s pen, a quality & safety review team has recommended further evaluation of additional system safety measures for insulin pen use An interprofessional HFMEA team is convened HFMEA = healthcare failure mode and effects analysis Healthcare Failure Mode and Effects Analysis (HFMEA) Definition Prospective, systematic approach to identify system vulnerabilities and to make corrections before errors occur 5-Step process Define topic Assemble multidisciplinary team Graphically describe the process Conduct hazard analysis Determine actions and outcome measures DeRosier J et al. Jt Comm J Qual Improv. 2002; 28: Stalhandske E et al. Patient Saf Qual Healthc. 2009; 20; (accessed 2014 Oct 2). Selection / Procurement Medication Use Process Storage Prescribing Brainstorm what could go wrong ( failure modes - FM) for each step List steps under each process Preparing Dispensing Administering HFMEA: Calculate FM Risk Hazard Score (Risk) = Frequency x Severity Severity Catastrophic (4) Major (3) Moderate (2) Minor (1) Remote (1) Uncommon (2) Frequency Occasional (3) Frequent (4) 6

7 Insulin Pens & Bloodborne Viral Illness What is higher risk? Disease transmission due to insulin pen sharing or potential of insulin overdosing with vial and syringe? Where there s smoke Published investigations Type and volume of biologic material that aspirates into pen cartridge is adequate to transmit viral disease Is there fire? Known reports of pen sharing No case of viral disease transmission has been confirmed What about the unknown? Le Floch JP et al. Diabetes Care. 1998; 21: Sonoki K et al. Diabetes Care. 2001; 24: Herdman ML et al. Am J Health-Syst Pharm. 2013; 70: Blood-Borne Viral Illness vs. Hypoglycemia Calculating Risk: Severity HIV, Hepatitis B & C Non-acute Not immediately detectable Not all have symptoms; may be non-specific, later Chronic: liver damage, cirrhosis, cancer, opportunistic infection, death Treatable- Yes Curable? Hypoglycemia Acute Detectable Shakiness, anxiety, sweating, confusion, lethargy, coma, death Treatable D50, glucose, glucagon General definitions 4 Catastrophic Death or permanent loss of function, suicide, rape, hemolytic transfusion reaction, wrong site or wrong patient surgery 3 Major Permanent lessening of body function, disfigurement, surgical intervention 2 Moderate Increased length of stay (LOS) or level of care 1 Minor No injury, increased length of stay or level of care Insulin specific??? 4 Catastrophic Hypoglycemia-related neurologic injury or death Hepatitis B/C, HIV transmission Viral-disease related liver failure, cancer, death 3 Major Hepatitis B/C, or HIV exposure 2 Moderate Severe hypoglycemia responding to treatment with increased LOS, level of care 1 Minor Mild-moderate hypoglycemia responding to treatment with no increased LOS, level of care (accessed 2014 Oct 2). Calculating Risk: Frequency General definitions 4 Frequent Likely to occur immediately or within short period (i.e., several times per year) 3 Occasional Probably will occur (i.e., several times in 1-2 years) 2 Uncommon Possible to occur (i.e., sometime in 2-5 years) 1 Remote Unlikely to occur (i.e., sometime in 5-30 years) Insulin pen specific??? 4 Frequent Likely to occur immediately or within short period (i.e., weekly to monthly) 3 Occasional Probably will occur (i.e., every few months) 2 Uncommon Possible to occur (i.e., every 1-5 years) 1 Remote Unlikely to occur (i.e., sometime in 5 to 30 years) (accessed 2014 Oct 2). HFMEA: Decision Tree Analysis If hazard score 8, proceed Single point weakness? (Yes / No) Is process step so critical that its failure will result in system failure or an adverse event? Existing control measure? (Yes / No) Is there an existing barrier that eliminates or substantially reduces likelihood of hazardous event occurring? Detectable? (Yes / No) Is failure mode so visible or obvious that it will be discovered before it interferes with completion of task and activity? If Red to any, proceed to action planning If Green to all 3, stop (focus attention elsewhere) (accessed 2014 Oct 2). 7

8 Preparation Process Evaluation Failure Mode Tamper-evident tape omitted or applied incorrectly Label not applied Label applied incorrectly (on cap or insecure) Label applied to wrong pen type Risk Increase (Infectious; Hypoglycemia) (I)- Used pen redispensed (I)- Unlabeled syringe used in multiple patients (I)- Unlabeled syringe or switched patient labels (H)- Wrong insulin error Potential Causes Forgot to apply Training deficit Forgot to apply Knowledge deficit Forgot right process >1 pen stocked Storage proximity Look-alike Actions (to address FM causes) Apply tape upon receiving, before putting into stock Program system to print pen label only (not bag label too) Staff education Include process instructions on prep label or post in prep area Limit to 1 pen on formulary If >1 pen Separate storage Improved bin labeling Implement scan on dispense Insulin Pen Wrong Insulin Errors Contributing factors More than one insulin pen on inpatient formulary BCMA not implemented BCMA is implemented and patient-specific barcode used at sites with more than one insulin pen BCMA = barcode medication administration Failure Mode Delivered to non-patient specific location Delivered to incorrect patient-specific location Dispensing Process Evaluation Risk Increase (Infectious; Hypoglycemia) (I)- Wrong pen used in another patient (I)- Wrong pen used in another patient Potential Causes Institution has not implemented pt-specific storage location Process noncompliance Proximity to other storage locations Similar-looking labeling of storage locations Actions (to address FM causes) Implement clearly-defined, wellmarked patient-specific medication storage locations Decrease storage location proximity Improve storage location labeling Administration Process Evaluation Failure Mode RN has wrong patient s pen at bedside Risk (Infectious; Hypoglycemia) (I, H)- Injection with wrong patient s pen +/- wrong insulin type Potential Causes Patient-specific storage location not implemented Removal of > 1 patient s pen at a time from storage Pen dispensed by pharmacy or returned by RN to incorrect storage Another patient s pen not removed from storage in timely fashion upon transfer or discharge Actions (to address FM causes) Address environment, workflow, workload, culture issues that lead to work-arounds Decrease storage location proximity Improve storage location labeling Implement use of checklists for patient transfer and discharge that include management of dispensed medications RN education or coaching Administration Process Evaluation Failure Mode RN does not scan RN scans after admin RN scans; does not identify wrong pen RN uses wrong administration technique Risk (Infectious; Hypoglycemia) (I, H)- Wrong insulin type and/or wrong patient s pen (I, H)- Wrong insulin type and/or wrong patient s pen (I, H)- Wrong insulin type and/or wrong patient s pen (I, H)- Wrong insulin dose and/or RN needlestick Potential Causes BCMA not implemented BCMA equipment or barcode malfunction Noncompliance BCMA equipment not available Noncompliance Manufacturer barcode scanned Does not recognize wrong-pen alert Inadequate training Noncompliance Pen used lacked needle safety cover Actions (to address FM causes) Implement BCMA Fix equipment BCMA compliance report monitoring RN education or coaching BCMA emar edit report monitoring RN education or coaching Implement order-specific barcode RN education / coaching 2-RN double-check? RN education or coaching Change pen needles to those with safety cover (prevents needlesticks after patient injection) Case Vignette (Revisited) Anywhere Medical Center HFMEA complete Recommendations Reduce pen use to 1 insulin only (rapid-acting) Reevaluate insulin pen policy and procedure Implement identified best practice system changes, including use of an order-specific barcode Provide staff education 8

9 In your hospital or healthcare facility, how many types of insulin are provided in pen form? a. 0 b. 1 c. 2 d. 3 or more e. Not currently practicing in hospital or healthcare facility Insulin Pen Safety Process Improvement Healthcare failure mode & effects analysis (HFMEA) Plan Do Act?? Check Implement system & process Educate (initial & ongoing) Error reports Ask / survey Observation Audits BCMA alerts Develop Written Procedures for Dispensing, Storage, Administration Dispensing Label Label on pen barrel, NOT cap Contains patient name and ID number Provide expiration date If bar-code: assure not obstructed Consider Warning statement: Sharing pens may result in disease exposure Tamper-evident seal perpendicular YES NO Dispense in bag without label Storage Standardize Maintain in secure location Patient-specific bin Provide tall man lettering Designate as high-alert medication Prohibit storage of pens from home Specify storage of pens after use Administration Perform patient verification Visual verification of patient name, drug Bar-code technology Ensure intended type of insulin If label missing or illegible, discard and request new pen 9

10 Administration Only remove pen from patient-specific bin when needed Do not place in pocket Do not leave at bedside or nursing station Develop procedure for contact isolation Clean pen with disinfectant and place in plastic bag Develop procedure for administration technique Provide link to video Administration Emphasize potential errors and safe practices Errors Causes Safe Practices Use of pen for multiple patients Blood and tissue can travel back into Never share patient-specific pen places patients at risk of infection insulin pen cartridge between patients (e.g., HIV, hepatitis B and C) Withdrawing insulin out of cartridge Damages the integrity of the pen and Not advised unless pen malfunction or with a syringe can introduce pockets of air, leading to emergency if done, discard pen inaccurate dosing with subsequent pen use Wet spots noted on skin post 1. May be that the air shot of insulin 1. When performing a 2-unit air shot, injection collects in the cylinder of the safety repeat until at least one drop of needle insulin appears on tip of needle May indicate failure to deliver This ensures that no air is being entire dose or excess insulin delivered collected in safety needle Shake off any excess insulin that chamber collects in chamber of safety needle 2. May be result of removal of the 2. When injecting, push the plunger all safety needle before all of the the way down and wait 6 seconds insulin is delivered before withdrawing the needle RN needlestick injuries When pinching the back of the arm of 1. Maintain a 90-degree angle during a lean patient, there is a greater risk the injection of a needlestick injury 2. Inject in abdomen or thigh whenever possible See enlargement p. 14 Staff Education Orientation Review policy/procedure Emphasize potential errors One-on-one coaching on technique for RNs Assess competency Mandatory annual education Routine short communication meetings Reminder notes with warnings about sharing Label Medication administration record Pen needle bins Medication administration room Solicit feedback from RN and pharmacy staff Do your policies and procedures address all components discussed? a. Yes b. No c. Not currently practicing in hospital using insulin pens Cobaugh DJ et al. Am J Health-Syst Pharm ;70: ISMP Acute Care Medication Safety Alerts (accessed 2014 Oct 16). Feb 7, 2013: May 8, 2008: Methods for Evaluating Safety of Actual Practices Review voluntarily-submitted error reports Survey nursing staff Conduct direct observation Conduct insulin pen storage and labeling audit Monitor BCMA scanning compliance and wrong-pen alerts See enlargement p

11 Sample question Which of the following is/are TRUE/CORRECT statement(s) regarding the use of insulin pen devices? (Select all that apply) a. Insulin pen devices should be primed (e.g., give an air shot ) such that a drop appears at the end of the needle prior to each and every use. b. After injecting insulin into the patient, the pen should be held against the skin for at least 5 or 6 seconds before withdrawing the needle. c. After administration, a drop of fluid on the skin indicates that a portion of the dose has leaked from the injection site. d. The routine use of insulin pen devices significantly reduces the transmission of infections in hospitals. e. Studies have shown that using insulin pen devices leads to more dosing errors when compared with the traditional insulin vial and syringe method. See enlargement p. 15 See enlargement p. 15 Direct Observation Storage and Labeling Audit Injection Observation Checklist.pdf Pen Storage and Labeling Audit.pdf See enlargement p. 16 See enlargement p. 16 Methods for Evaluating Safety of Actual Practices Review voluntarily-submitted error reports Survey nursing staff Conduct direct observation Conduct insulin pen storage and labeling audit Monitor BCMA scanning compliance and wrong-pen alerts To what extent has barcode medication administration been implemented at your institution? a. No BCMA b. BCMA- manufacturer s barcode for insulin c. BCMA- order-specific barcode for insulin d. Not applicable (non-hospital participant) 11

12 Insulin Pen Injection Safety: Role of BCMA Report Monitoring Optimal when order- or patientspecific barcode is implemented Work with Information Technology if reports not already available What to look for? Total number of administrations Patient and medication scanning performed» % compliance Near misses» Wrong pen alert, followed by administration documentation with correct pen barcode scan Wrong pen injections» Wrong pen alert, followed by manual administration documentation without barcode scanning What are the appropriate steps to take in a specific event where an insulin pen is used in more than one patient? Insulin Pen Sharing: Follow Up Centers for Medicare and Medicaid Services Sharing of insulin pens is essentially the same as sharing needles or syringes. Centers for Disease Control and Prevention Protection from infections, including blood-borne pathogens, is a basic expectation anywhere healthcare is provided. Use of insulin pens for more than one person, like other forms of syringe reuse, imposes unacceptable risks and should be considered a 'never event'. If reuse is identified, exposed persons should be promptly notified and offered appropriate follow-up including bloodborne pathogen testing. (accessed 2014 Jun 20). CMS Director, Survey and Certification Group. Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter pdf (accessed 2014 Jul 26). Patient Exposure to Blood or Body Fluids: Policy and Procedure Assess and document details of event Notify attending physician & epidemiology Disclose to patient and perform blood-borne disease risk counseling Testing Source person Hepatitis B surface antigen and hepatitis C antibody, rapid HIV Exposed person Specific testing based on source person results Case Vignette (Revisited) Anywhere Medical Center insulin pen Best Practices were implemented Pens used for 1 insulin only (rapid-acting) System safety measures (including order-specific barcode) Extensive staff education Ongoing monitoring conducted (i.e., voluntary error reports, periodic pen administration and storage audits, and BCMA scanning reports) Three months later, the Chief Quality & Safety Officer wants a report of overall insulin pen safety Case Vignette: Three-Month Safety Report BCMA report monitoring 40,000 insulin pen administrations Correct Patient/Med Scanning 99.2% admins w/o scans Near Misses at bedside 0.5% wrong-pen injections averted Wrong Pen Injections 0.02% administrations Hepatitis B / C, or HIV seroconversion 0%. 0 cases Pen audits Administration No wrong pen injections; some incorrect technique findings not leading to obvious harm (i.e., wrong-dose hypoglycemia or RN needlestick) Storage 99% appropriate; 1% inappropriate (i.e., multiple pens in RN pockets, unapproved storage locations, left after patient transfer or discharge) Voluntary error reports None 12

13 Based on the 3-month safety report findings, your conclusion and recommendation is that inpatient insulin pen risk is a. Successfully mitigated; keep pens & continue current plan b. Successfully mitigated; expand use & continue current plan c. Unacceptably high; remove pens from formulary d. Unacceptably high; keep pens & make improvements Case Vignette: Alternative Three-Month Safety Report BCMA report monitoring 40,000 insulin pen administrations Correct Patient/Med Scanning 99.2% admins w/o scans Near Misses at bedside 0.5% wrong-pen injections averted Wrong Pen Injections %... 3 administrations Hepatitis B / C, or HIV seroconversion % case Pen audits Administration No wrong pen injections; some incorrect technique findings not leading to obvious harm (i.e., wrong-dose hypoglycemia or RN needlestick) Storage 99% appropriate; 1% inappropriate (i.e., multiple pens in RN pockets, unapproved storage locations, left after patient transfer / discharge) Voluntary error reports None Based on the 3-month safety report findings, your conclusion and recommendation is that inpatient insulin pen risk is a. Successfully mitigated; keep pens & continue current plan b. Successfully mitigated; expand use & continue current plan c. Unacceptably high; remove pens from formulary d. Unacceptably high; keep pens & make improvements Conclusion In the inpatient setting, insulin pen safety may be optimized by Understanding how environment, workflow processes, and culture each contribute to safety risks associated with use of insulin pen delivery systems Developing and implementing a plan for ensuring best practices in the use of insulin pen delivery systems in hospitals Monitoring insulin pen safety Making recommendations and implementing additional changes to ensure patient safety 13

14 Administration Emphasize potential errors and safe practices Errors Causes Safe Practices Use of pen for multiple patients places patients at risk of infection (e.g., HIV, hepatitis B and C) Withdrawing insulin out of cartridge with a syringe Wet spots noted on skin post injection May indicate failure to deliver entire dose or excess insulin collected in safety needle chamber RN needlestick injuries Blood and tissue can travel back into insulin pen cartridge Damages the integrity of the pen and can introduce pockets of air, leading to inaccurate dosing with subsequent pen use 1. May be that the air shot of insulin collects in the cylinder of the safety needle 2. May be result of removal of the safety needle before all of the insulin is delivered When pinching the back of the arm of a lean patient, there is a greater risk of a needlestick injury Never share patient-specific pen between patients Not advised unless pen malfunction or emergency if done, discard pen 1. When performing a 2-unit air shot, repeat until at least one drop of insulin appears on tip of needle This ensures that no air is being delivered Shake off any excess insulin that collects in chamber of safety needle 2. When injecting, push the plunger all the way down and wait 6 seconds before withdrawing the needle 1. Maintain a 90-degree angle during the injection 2. Inject in abdomen or thigh whenever possible 14

15 Sample question Which of the following is/are TRUE/CORRECT statement(s) regarding the use of insulin pen devices? (Select all that apply) a. Insulin pen devices should be primed (e.g., give an air shot ) such that a drop appears at the end of the needle prior to each and every use. b. After injecting insulin into the patient, the pen should be held against the skin for at least 5 or 6 seconds before withdrawing the needle. c. After administration, a drop of fluid on the skin indicates that a portion of the dose has leaked from the injection site. d. The routine use of insulin pen devices significantly reduces the transmission of infections in hospitals. e. Studies have shown that using insulin pen devices leads to more dosing errors when compared with the traditional insulin vial and syringe method

16 Direct Observation Injection Observation Checklist.pdf Storage and Labeling Audit Pen Storage and Labeling Audit.pdf 16

17 Ask the Experts: Safe Use of Insulin Pens in Hospitals Self-assessment Questions 1. When conducting a healthcare failure mode and effects analysis, an action plan should be developed for all of the following failure modes (FMs) EXCEPT a. FM with hazard ratio of 6 that is likely to be detected. b. FM with hazard ratio of 8 that is not likely to be prevented by existing barriers. c. FM with hazard ratio of 9 that will likely result in a system failure. d. FM with hazard ratio of 12 that is likely to cause an adverse event. 2. Which of the following is a best practice when labeling insulin pens for dispensing for hospitalized patients? a. Tamper-evident tape placed around pen between barrel and cap. b. Label placed on pen and on bag. c. Label placed on cap of insulin pen. d. Label contains patient name and ID number along with patient-specific barcode. 3. A wet spot appears on a patient s skin after administration of an insulin dose using an insulin pen with an automatic needle cover. The nurse had primed the pen with a 2-unit air shot, and when administering the insulin, the nurse had pushed the plunger down and waited six seconds before withdrawing the needle. The patient expresses concern that only a partial dose was administered. Which of the following is the most appropriate response to address the patient s concerns about the wet spot? a. Most likely the wet spot is the result of priming the needle and insulin collecting in the cylinder of the safety needle because the nurse waited 6 seconds before withdrawing the needle. b. Most likely the wet spot is a portion of the insulin dose because the nurse did not wait at least 8 seconds before withdrawing the needle. c. Any wet spot on the skin after an insulin injection indicates that only a partial dose was administered, and a second dose should be administered. d. The wet spot indicates that the insulin pen is defective and will be replaced before the next dose. Answers 1. a 2. d 3. a 17