Building on a safety culture with transparency by participating in a mentored quality-improvement program for insulin pen safety

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The experience at a medium-sized regional medical center participating in the ASHP MENTORED QUALITY IMPROVEMENT IMPACT PROGRAMSM (MQIIP) on Insulin Pen Safety in Hospitals is described.


With the support of top hospital leaders, Munson Medical Center (MMC) applied in June 2014 to participate in the MQIIP to complement its ongoing risk assessment related to the use of pen devices for insulin administration. Nurse knowledge deficits, problems with insulin pen storage and labeling, and improper insulin injection practices identified in baseline assessments for the MQIIP were the basis for process improvements, including new policies and procedures, an electronic alert and education for nurses, and individualized communication with pharmacy and nursing personnel about insulin pen safety. The experiences of other hospitals helped us identify solutions to safety issues and formulate communication strategies for improving insulin pen safety in our hospital. Awareness of the importance of insulin pen safety increased in all staff. Implementing these process improvements during the five-month intervention period resulted in increases in nurse knowledge and improvements in insulin pen storage, labeling, and injection practices, although problems persisted. Additional plans have been made to further enhance the safety of insulin use at MMC.


The ASHP MQIIP on Insulin Pen Safety in Hospitals provided a structured and supportive approach to identifying and addressing insulin pen safety issues at MMC. The insight gained through participation enabled us to devise strategies to communicate with staff about safety issues and improve the safety of insulin pen use in the institution.

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