Development and Implementation of a Subcutaneous Insulin Pen Label Bar Code Scanning Protocol to Prevent Wrong-Patient Insulin Pen Errors.

PROBLEM DEFINITION: Insulin, a high-alert medication, is regularly prescribed in the inpatient setting for hyperglycemia and diabetes mellitus. Although convenient, insulin pens carry a risk of blood-borne pathogens if the same pen is used on multiple patients. At the University of California, San Francisco (UCSF), a new nursing protocol for insulin pen administration was developed to ensure that insulin was quickly available and to identify and move to eliminate wrong-patient insulin pen errors. This protocol involved unit-based automated dispensing machines and an electronic health record (EHR)-integrated patient-specific bar code label work flow. APPROACH: After piloting on three hospital units, this new patient-specific bar code label process was expanded hospitalwide. "Print Label For Insulin Pen" and "Scan Insulin Pen" buttons were programmed into the EHR to enable nurses to print patient-specific bar code labels. In addition, a "wrong-patient pen alert" was activated to prevent wrong-pen insulin pen administration. OUTCOMES: For the 162,075 inpatient insulin pen administrations during the study period (April 2017-March 2018), monthly errors (rates) ranged from 13 (0.12%) to 36 (0.23%). In total, 296 near-miss events (0.18% of all insulin pen administrations) were observed and prevented. CONCLUSION: Insulin pen work flow and EHR changes implemented at UCSF enable subcutaneous insulin to remain a time-critical medication and ensure patient safety. The wide adoption of EHRs offers an opportunity to integrate patient safety improvements directly into the electronic medication administration record systems to maximize patient safety.

Decreasing triage time: effects of implementing a step-wise ESI algorithm in an EHR.

OBJECTIVES: To determine if adapting a widely-used triage scale into a computerized algorithm in an electronic health record (EHR) shortens emergency department (ED) triage time. DESIGN: Before-and-after quasi-experimental study. SETTING: Urban, tertiary care hospital ED. PARTICIPANTS: Consecutive adult patient visits between July 2011 and June 2013. INTERVENTION: A step-wise algorithm, based on the Emergency Severity Index (ESI-5) was programmed into the triage module of a commercial EHR. MAIN OUTCOME MEASURES: Duration of triage (triage interval) for all patients and change in percentage of high acuity patients (ESI 1 and 2) completing triage within 15 min, 12 months before-and-after implementation of the algorithm. Multivariable analysis adjusted for confounders; interrupted time series demonstrated effects over time. Secondary outcomes examined quality metrics and patient flow. RESULTS: About 32 546 patient visits before and 33 032 after the intervention were included. Post-intervention patients were slightly older, census was higher and admission rate slightly increased. Median triage interval was 5.92 min (interquartile ranges, IQR 4.2-8.73) before and 2.8 min (IQR 1.88-4.23) after the intervention (P < 0.001). Adjusted mean triage interval decreased 3.4 min (95% CI: -3.6, -3.2). The proportion of high acuity patients completing triage within 15 min increased from 63.9% (95% CI 62.5, 65.2%) to 75.0% (95% CI 73.8, 76.1). Monthly time series demonstrated immediate and sustained improvement following the intervention. Return visits within 72 h and door-to-balloon time were unchanged. Total length of stay was similar. CONCLUSION: The computerized triage scale improved speed of triage, allowing more high acuity patients to be seen within recommended timeframes, without notable impact on quality.