While it is well known that insulin is a high risk medication and there is potential for serious patient harm if insulin and insulin pens are not used appropriately, it is often challenging for health care providers to pinpoint the potential safety risks and implement process improvements. This mentored program was designed to provide practitioners with the information needed to advocate for best practices for the use of insulin in the hospital setting and with practical tools and strategies to facilitate the safe and appropriate use of insulin pens in the hospital setting using a team-based approach.

Ensuring the safe and appropriate use of insulin and insulin pens in the hospital setting is not the responsibility of a single type of health care professional. For process improvements to be effective, the entire team, including hospital leadership, must support these activities. This quality improvement program recognized that to be part of a new process, everyone needed to come together to develop it.

This mentored program was developed specifically to help practitioners improve the safe and appropriate use of insulin pen devices in U.S. hospitals that currently were using them. Applicants were from hospitals that were motivated to look closely at their processes related to the use of insulin pens and were willing to make change – process changes that address potential safety risks. Many teams were led by a pharmacist, but they could have been led by a physician, physician assistant, or nurse.

A variety of professionals were part of the team. The team included both frontline providers and managers, including physicians, physician assistants, pharmacists, nurses, and information technology specialists. The team members contributed a variety of knowledge and experience about patient care, glycemic control, process improvement, and medication safety.

All correspondence was sent to the Team Leader. The Team Leader was responsible for working with ASHP Advantage staff to coordinate all aspects of the mentored program. The Team Leader was also the primary contact for the Faculty Mentors.

In addition to the online application, an Applicant Agreement signed by both the team leader and hospital leadership was required to complete the application process. The Applicant Agreement was necessary to demonstrate to the Selection Panel that hospital leadership supports participation in the quality improvement initiative and will help make the mentored program productive.

All site teams were required to collect baseline data between the first and second mentored calls and then repeat the data collection at the end of the implementation period, including observations of insulin administration using pen devices and an audit of pen storage on several units. The observations were completed during the period of meal time administration of insulin (breakfast, lunch, and dinner) and in the evening for three different units. Sites were encouraged to have multiple team members, as well as students, residents, or technicians, conduct the observations. Team members entered these data into the online data management tool before the second mentored call and again at the end of the implementation period, and the data were made available to the faculty mentors so that they could provide suggestions for possible strategies for mitigating safety risks. The results from all sites were pooled to determine the effect of the mentored activity.

In addition, sites were required to send a hyperlink to a brief online survey to the hospital’s inpatient nursing staff as part of the baseline and post-implementation data collection. The survey was developed by ASHP, and results were collated by ASHP and returned to Team Leaders. Site teams were encouraged to collect any other data that would be pertinent for identifying potential safety risks and measuring the impact of their process improvements.

While some site teams may have had ideas of goals for a process improvement and possible interventions at the time of application, it was anticipated that the process of collecting baseline data would be useful in identifying potential safety risks. Then through the educational webinar and first two mentored calls, teams got feedback and ideas for potential strategies for process improvements. The 180-day implementation period started with the second mentored call, and each site was expected to begin developing its plan within 30 days of that call, implementing it within the next month or two. That way, the process improvements were in effect for three or four months before post-implementation observational data were collected. Mentors were able to assist participants, if needed, in refining the plan before implementation.

A total of 15 sites were selected to participate, with 14 sites completing the program.

The mentors were pharmacists with expertise in glycemic control and medication safety, and all had experience using pen devices for insulin delivery in their hospitals.  

There was no fee for applying or participating in the Mentored Quality Improvement Impact Program for Insulin Pen Safety.

This mentored program was part of a larger educational initiative developed by a steering committee comprised of pharmacists with expertise in inpatient glycemic control and medication safety. The initiative was coordinated by ASHP Advantage, a division of the American Society of Health-System Pharmacists. It was supported by an educational grant from Novo Nordisk Inc.

Mentor responsibilities

• Review submitted participant materials
• Conduct four mentored calls with participating sites (up to 5 sites in each call)

Mentee and participating hospital responsibilities

• Participate in CE webinar or view archived webinar
• Provide materials to ASHP Advantage in preparation for the mentoring activities, including existing hospital protocols and policy and procedure documents related to glycemic control and insulin pen use
• Collect and report baseline data before the second mentored call, including a total of 45 observed injections using insulin pens (15 on each of three wards), audit of insulin pen storage on three wards, and a brief nursing survey.
• Develop, submit, and implement a plan for a process improvement intended to improve safe and appropriate use of insulin pens in the hospital within 30-60 days after the second mentored call
• Collect and report post-implementation data (similar to the initial observations) before the final mentored call
• Submit final report in PowerPoint format (template provided) within two weeks of final mentored call

Review the AJHP supplement entitled, “Best Practices in Ensuring the Safe Use of Insulin Pens in the Hospital,”  which was published on October 1, 2016. Three of the four articles in this supplement focus on the initiative’s mentored quality improvement program—the methods used to collect baseline insulin pen use safety data, the opportunities for improvement identified, the changes implemented, and the improvements realized, as well as the perspectives of the team leaders from two participating sites. The supplement also contains an article outlining best practices related to the use of insulin pen devices in hospitals as determined by an expert panel using the Delphi consensus development process.

Yes, the tools developed to identify potential problems in the medication-use process and assess the impact of quality improvement efforts related to insulin pens are available in the Tool Kit. They are available in Word format so that they can be customized for use within individual institutions.