Hello all,

We have been having multiple issues with insulin pens being used on the wrong patient or not labeled correctly. There are multiple layers to it. Nutshell...our current process is the pens are stored in pyxis and RN pulls a pen and a label prints that they date for 28 days (no barcode on this label, not a capability of this zebra printer). The pen is stored in the patient's drawer and used on that patient throughout their admission. When the patient is discharged, environmental services cleans the room and alerts the nurse to check the drawer for meds (they aren't allowed to handle the meds themselves). This does not always get done. When a pen is left in the drawer, it may get administered to the wrong patient because they scan the pen itself on administration, not a patient specific label since it comes from pyxis. We then have to test patients to ensure no harm was done due to pen sharing. Pharmacy used to empty drawers when we had a cart fill process, but now that we are cartless, going into each room or drawer would be an additional step.

Looking for those willing to share their processes and how those are going or any advice for us in our process that could be helpful. Thanks!