No abstract

This paper describes a multifaceted patient safety project undertaken to address the complex medication safety issues of single-patient insulin pens in the hospital setting. The project makes the following contributions: a) provides observation- and data-based insight into root causes for the wrong pen/wrong patient problem; b) provides multiple solutions that can work together to significantly reduce the incidence of insulin pen-related safety events; c) shows how Quality and Safety methodologies can work hand-in-hand with human factors and human computer interaction methodologies to produce richer, more in depth results, and d) confirm expert recommendations for best practices that can reduce risks.