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 han… Show more
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