Randomized controlled evaluation of an insulin pen storage policy

Haley G. Gibbs, Tara McLernon, Rosemary Call, Katie Outten, Leigh Efird, Peter A. Doyle, Elizabeth A. Stuart, Nestoras Mathioudakis, Nicole Glasgow, Avadhut Joshi, Pravin George, Bob Feroli, Elizabeth K. Zink

Research output: Contribution to journalArticlepeer-review

1 Scopus citations


Purpose. Results of a quality-improvement project to enhance safeguards against “wrong-pen-to-patient” insulin pen errors by permitting secure bedside storage of insulin pens are reported. Methods. A cluster-randomized controlled evaluation was conducted at an academic medical center to assess adherence with institutional policy on insulin pen storage before and after implementation of a revised policy allowing pen storage in locking boxes in patient rooms. In phase 1 of the study, baseline data on policy adherence were captured for 8 patient care units (4 designated as intervention units and 4 designated as control units). In phase 2, policy adherence was assessed through direct observation during weekly audits after lock boxes were installed on intervention units and education on proper insulin pen storage was provided to nurses in all 8 units. Results. Phase 1 rates of adherence to insulin pen storage policy were 59% in the intervention units and 49% in the control units (p = 0.56). During phase 2, there was no significant change from baseline in control unit adherence (67%, p = 0.26), but adherence in intervention units improved significantly, to 89% (p = 0.005). Common types of observed nonadherence included pens being unsecured in patient rooms or nurses' pockets or left in patient-specific medication drawers after patient discharge. Conclusion. An institutional policy change permitting secure storage of insulin pens close to the point of care, paired with nurse education, increased adherence more than education alone.

Original languageEnglish (US)
Pages (from-to)2054-2059
Number of pages6
JournalAmerican Journal of Health-System Pharmacy
Issue number24
StatePublished - Dec 15 2017


  • Insulin
  • Nurses
  • Patient safety
  • Policy guideline adherence

ASJC Scopus subject areas

  • Pharmacology
  • Health Policy


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