'Wrong Patient' Insulin Pen Injections Alarmingly Frequent Even With Barcode Scanning

The Institute for Safe Medication Practices (ISMP) learned about some rather alarming data associated with what could be called “best practices” for proper insulin pen use in a multihospital system. The best practices employed by these hospitals to prevent the sharing of insulin pens between multiple patients included one-on-one staff education regarding the safe use of insulin pens; implementation of barcode scanning of both the patient barcode and the patient- and order-specific barcode on the insulin pen; an electronic medication administration record (eMAR) at the bedside; and an effective monitoring system. Despite these strategies to prevent the sharing of insulin pens, errors still occurred for reasons beyond a knowledge deficit or mistaken belief that changing the needle is sufficient to prevent cross-contamination when sharing pens.