Staff at a Maryland hospital discovered a patient safety issue with insulin pens that was traced to the electronic medical record’s (EMR) inability to generate patient-specific labels efficiently. A root cause analysis revealed the process gaps, and staff developed a solution that ensures patients receive insulin doses only from their own pens.

The project was a high priority because of the potential danger from improper dispensing and use of insulin pens, says Vaishali Khushalani, MS, PharmD, medication safety officer and pharmacy residency program coordinator at Greater Baltimore Medical Center (GBMC) in Towson, MD.

Insulin is a high-alert medication, and insulin pens cannot be shared among patients. Sharing pens can expose patients to bloodborne pathogens like hepatitis B. Staff at GBMC determined there was a patient safety issue involving the labeling and dispensing of insulin pens. The quality improvement effort began when a nurse needed to give a dose of insulin to a patient in the ICU. She went to retrieve the insulin pen from a bin in the medication room and found several pens. There were three NovoLog pens labeled for that patient, but there was another NovoLog pen in the same bin labeled for another patient.

This caused the nurse to wonder if the other patient had received insulin from a pen labeled for the first patient, so she reported the incident, and the second patient was tested for bloodborne pathogens. The tests were negative.

Barcode Labels at Issue

The quality department conducted a root cause analysis and found that although the hospital used barcode scanning for the insulin pens, staff had to scan the manufacturer’s National Drug Code (NDC) barcode instead of a label that was both patient- and dose-specific.

Scanning the NDC barcode was standard process for bulk items, including insulin pens, because the hospital’s EMR could not generate labels that were patient- and product-specific, and would scan for multiple orders of something like insulin pens.

If the patient required a change in dose or frequency, a new label would have meant sending a new pen with an updated label each time, after retrieving the existing pen. To avoid that kind of delay, the hospital instructed nurses to scan the NDC barcode instead.

“Sending a new pen with a new label every time the dose was changed would be very wasteful,” Khushalani explains. “We decided at that time, like many other institutions, that scanning the NDC code was proper because it would tell the nurse that you are correctly scanning insulin aspart.”

However, that created a scenario in which a nurse might accidentally scan an insulin pen from one patient and administer it to another.

Multiple Pens Dispensed

An additional problem was pharmacists often had to dispense multiple insulin pens to a single patient, using a manual process that required them to remember to review each patient’s chart for changes to the order. If a pen had been dispensed already, they were to cancel the new order for an insulin pen, but that was not always caught. Multiple pens could be dispensed when they were not needed.

“We were dispensing a whole lot of pens. We had a system that told pharmacists to see if a pen had been dispensed when verifying the dose, and if so, don’t send it,” Khushalani says. “But that was just a reminder. We didn’t have anything in the system to force that not to happen.”

When searching for solutions, the biggest barrier was the hospital’s Epic EMR. GBMC first tried to work with Epic to find a solution that would allow the kind of patient- and medication-specific labeling that would allow for the multiple doses and dose changes. However, the company was unable to meet these needs.

GBMC then sought help from other hospitals. Johns Hopkins University reported they had found a way for the Epic EMR to do what GBMC needed. The hospital worked with Epic and Hopkins to modify the GBMC EMR.

“This new barcode links to the patient and all the insulin aspart orders that a patient could have. When a nurse scans the patient barcode, what shows up is all the patient’s insulin aspart orders, and they can document appropriately,” Khushalani says. “If they scan that barcode and it is for a different patient, that is a hard stop.”

One Pen Per Patient

The hospital also wanted to ensure every patient prescribed an insulin pen received such an item.

“We have had a robust process improvement culture in this institution, so we were oriented to process redesign,” Khushalani says. “We started looking at our metrics for sending new pens when there was a new order, seeking to ensure that for every patient who has an order for an insulin pen, we send a pen.”

The hospital developed a daily report on all missed insulin pen dispenses that was presented to the executive team. They used a Pareto chart to identify the most common reason for patients not receiving insulin pens: The pharmacist simply forgot to dispense it.

“We wanted to put something in the system that would remind the pharmacist, so we added a best practice advisory during the verification process that asks if you have dispensed the pen,” Khushalani says. “They have to answer ‘already dispensed’ or ‘I’m going to dispense.’ What we really wanted was to have it require the pharmacist to dispense the pen now instead of saying you will do it, but Epic is not capable of doing that for us now.”

That prompt resulted in a sharp decrease in failures to dispense insulin pens. GBMC also tracks misses by individual pharmacists and intervenes with reminders for them as necessary.

The data also revealed there was a higher incidence of failure to dispense insulin pens on the night shift. The hospital began sending an automatic email in the middle of the night to remind night shift pharmacists to catch up on non-dispenses.

Misses Drop Sharply

The day shift pharmacists also began their shifts with a review of night shift insulin pen orders dispensed overnight, acting on any that had not been sent to the patient.

“Within a few months, there were hardly any misses. In May, we had about 67 pharmacist failure-to-dispenses, but by December we were down to 14,” Khushalani reports. “Most days are zero to two. We’d like that to be zero, but we’d need a little more help from the EMR system to do that.”

Khushalani says one of the lessons is to never take no for an answer when trying to find a solution to quality and patient safety issues. Initially stymied when they tried to modify the EMR to help with insulin pen dispensing, GBMC found a solution by contacting other institutions.

“Support from leadership is so important. The culture of safety is highly valued here. A really big, helpful push was how our chief medical officer and our vice president of quality were involved and pushing this project right from the beginning,” Khushalani says. “The other thing that was quite helpful was that we had a mechanism in place with Lean management to address these issues once they were identified.”


  • Vaishali Khushalani, MS, PharmD, Medication Safety Officer and Pharmacy Residency Program Coordinator, Greater Baltimore Medical Center, Towson, MD. Phone: (443) 849-2923. Email: