It’s Like Scanning the Spoon: Problems and Interventions in Insulin Pen Safety

2018 ◽  
Vol 7 (1) ◽  
pp. 213-217
Author(s):  
Susan Harkness Regli ◽  
Suzanna Ho ◽  
Margaret Yoho ◽  
Ilona Lorincz ◽  
Rebecca Stamm ◽  
...  
Keyword(s):  
Best Practices ◽  
Medication Safety ◽  
Multiple Solutions ◽  
Hospital Setting ◽  
Quality And Safety ◽  
Single Patient ◽  
Safety Issues ◽  
Insulin Pens ◽  
Insight Into ◽  
Expert Recommendations

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.

Inpatient Insulin Pen Implementation, Waste, and Potential Cost Savings: A Community Hospital Experience

2021 ◽  
pp. 193229682110025
Author(s):  
Urooj Najmi ◽  
Waqas Zia Haque ◽  
Umair Ansari ◽  
Eyerusalem Yemane ◽  
Lee Ann Alexander ◽  
...  
Keyword(s):  
Insulin Aspart ◽  
Community Hospital ◽  
Task Force ◽  
Hospital Setting ◽  
Cost Savings ◽  
Self Management ◽  
Self Administration ◽  
Potential Cost ◽  
Hospital Leadership ◽  
Insulin Pens

Background: Insulin pen injectors (“pens”) are intended to facilitate a patient’s self-administration of insulin and can be used in hospitalized patients as a learning opportunity. Unnecessary or duplicate dispensation of insulin pens is associated with increased healthcare costs. Methods: Inpatient dispensation of insulin pens in a 240-bed community hospital between July 2018 and July 2019 was analyzed. We calculated the percentage of insulin pens unnecessarily dispensed for patients who had the same type of insulin pen assigned. The estimated cost of insulin pen waste was calculated. A pharmacist-led task force group implemented hospital-wide awareness and collaborated with hospital leadership to define goals and interventions. Results: 9516 insulin pens were dispensed to 3121 patients. Of the pens dispensed, 6451 (68%) were insulin aspart and 3065 (32%) were glargine. Among patients on insulin aspart, an average of 2.2 aspart pens was dispensed per patient, but only an estimated 1.2 pens/patient were deemed necessary. Similarly, for inpatients prescribed glargine, an average of 2.1 pens/patient was dispensed, but only 1.3 pens/patient were necessary. A number of gaps were identified and interventions were undertaken to reduce insulin pen waste, which resulted in a significant decrease in both aspart (p = 0.0002) and glargine (p = 0.0005) pens/patient over time. Reductions in pen waste resulted in an estimated cost savings of $66 261 per year. Conclusions: In a community hospital setting, identification of causes leading to unnecessary insulin dispensation and implementation of hospital-wide staff education led to change in insulin pen dispensation practice. These changes translated into considerable cost savings and facilitated diabetes self-management education.

scholarly journals Challenges for Change Agents. Best Practices at the University Library of Freie Universität Berlin

ABI-Technik ◽  
2020 ◽  
Vol 40 (4) ◽  
pp. 357-364
Author(s):  
Martin Lee ◽  
Christina Riesenweber
Keyword(s):  
Best Practices ◽  
Change Agents ◽  
Large Change ◽  
University Library ◽  
The Future ◽  
The University ◽  
Insight Into

AbstractThe authors of this article have been managing a large change project at the university library of Freie Universität Berlin since January 2019. At the time of writing this in the summer of 2020, the project is about halfway completed. With this text, we would like to give some insight into our work and the challenges we faced, thereby starting conversations with similar undertakings in the future.

scholarly journals The Synthesis Map Is a Multidimensional Educational Tool That Provides Insight into Students’ Mental Models and Promotes Students’ Synthetic Knowledge Generation

2015 ◽  
Vol 14 (2) ◽  
pp. ar14 ◽  
Author(s):  
Ryan A. Ortega ◽  
Cynthia J. Brame
Keyword(s):  
Best Practices ◽  
Concept Mapping ◽  
Student Understanding ◽  
Knowledge Structures ◽  
Cognitive Domain ◽  
Knowledge Generation ◽  
Natural Evolution ◽  
Student Work ◽  
Presentation Software ◽  
Insight Into

Concept mapping was developed as a method of displaying and organizing hierarchical knowledge structures. Using the new, multidimensional presentation software Prezi, we have developed a new teaching technique designed to engage higher-level skills in the cognitive domain. This tool, synthesis mapping, is a natural evolution of concept mapping, which utilizes embedding to layer information within concepts. Prezi’s zooming user interface lets the author of the presentation use both depth as well as distance to show connections between data, ideas, and concepts. Students in the class Biology of Cancer created synthesis maps to illustrate their knowledge of tumorigenesis. Students used multiple organizational schemes to build their maps. We present an analysis of student work, placing special emphasis on organization within student maps and how the organization of knowledge structures in student maps can reveal strengths and weaknesses in student understanding or instruction. We also provide a discussion of best practices for instructors who would like to implement synthesis mapping in their classrooms.

A Static Game Study between Food Enterprises Based on Value Perception Differences of Food Quality and Safety

2013 ◽  
Vol 791-793 ◽  
pp. 2171-2174
Author(s):  
Yuan Fen Yin ◽  
Yun Deng ◽  
Xiu Li Sang
Keyword(s):  
Food Quality ◽  
Game Model ◽  
Quality And Safety ◽  
Static Game ◽  
Safety Issues ◽  
Value Perception ◽  
Safety Mechanism ◽  
Psychology And Economics ◽  
Food Quality And Safety ◽  
Food Market

Behavior strategy of food enterprises exerts a direct influence on food quality and safety. Against the backdrop of value perception differences on food quality and safety between different food enterprises, this paper establishes a static game model and based on prospect theory, explores the reasons for food quality and safety issues in our food market from the perspectives of psychology and economics. Finally, it presents a more scientific food quality and safety mechanism and countermeasures.

scholarly journals Nursing students’ perception of safety in clinical settings: From the quality and safety officer

2017 ◽  
Vol 7 (10) ◽  
pp. 91 ◽  
Author(s):  
Elizabeth E. Cooper
Keyword(s):  
Nursing Students ◽  
Nursing Student ◽  
Near Miss ◽  
Clinical Settings ◽  
Primary Concern ◽  
Quality And Safety ◽  
Safety Issues ◽  
Perception Of Safety ◽  
Study Results ◽  
Safety Officer

Teaching methods to improve the safety of care for patients has been a priority for nurse educators. This article discusses the student nurses’ use of error reporting tools in the clinical setting, revealing study results completed by the Quality and Safety Officer in a School of Nursing and Health Professions. The aim was to report on the use of safety tools and the perception of safety issues in clinical settings identified by 121 prelicensure baccalaureate nursing students. Responses suggest that it is challenging for nursing students to report errors and near miss events. Barriers exist for the nursing student. The survey reveals difficulty in reporting but discloses that safety for the patient continues to be a primary concern for the nursing student.

scholarly journals Pictograms for Safer Medication Management by Health Care Workers

2016 ◽  
Vol 69 (4) ◽  
Author(s):  
Régis Vaillancourt ◽  
Annie Pouliot ◽  
Kim Streitenberger ◽  
Sylvia Hyland ◽  
Pierre Thabet
Keyword(s):  
Health Care ◽  
Medication Safety ◽  
Medication Management ◽  
Medication Administration ◽  
Delphi Process ◽  
Semiotic Analysis ◽  
Safety Issues ◽  
Personnel Infirmier ◽  
Nurses And Physicians ◽  
Pharmacy Technicians

<p><strong>ABSTRACT</strong></p><p><strong>Background:</strong> Inherent risks are associated with the preparation and administration of medications. As such, a key aspect of medication safety is to ensure safe medication management practices.</p><p><strong>Objective:</strong> To identify key medication safety issues and high-alert drug classes that might benefit from implementation of pictograms, for use by health care providers, to enhance medication administration safety. This study was the first step in the development of such pictograms.</p><p><strong>Methods:</strong> Self-identified medication management experts participated in a modified Delphi process to achieve consensus on situations where safety pictograms are required for labelling to optimize safe medication management. The study was divided into 3 phases: issue generation, issue reduction, and issue selection. Issues achieving at least 80% consensus and deemed most essential were selected for future studies. Retained issues were subjected to semiotic analysis, and preliminary pictograms were developed.</p><p><strong>Results:</strong> Of the 87 health care professionals (pharmacists, pharmacy technicians, nurses, and physicians) invited to participate in the Delphi process, 30 participated in all 3 phases. A total of 55 situations that could potentially benefit from safety pictograms were generated initially. Through the Delphi process, these were narrowed down to 10 situations where medication safety might be increased with the use of safety pictograms. For most of the retained issues, between 3 and 6 pictograms were designed, based on the results of the semiotic analysis.</p><p><strong>Conclusions:</strong> The pharmacists, pharmacy technicians, nurses, and physicians participating in this study reached consensus and identified 10 medication administration safety issues that might benefit from the development and implementation of safety pictograms. Pictograms were developed for a total of 9 issues. In follow-up studies, these pictograms will be validated for comprehension and evaluated for effectiveness.</p><p><strong>RÉSUMÉ</strong></p><p><strong>Contexte :</strong> Il y a des risques inhérents associés à la préparation et à l’administration de médicaments. Pour cette raison, l’un des principaux aspects de la sécurité des médicaments est d’assurer des pratiques de gestion des médicaments sécuritaires.</p><p><strong>Objectif :</strong> Déterminer les principales questions de sécurité des médicaments et les classes de médicaments de niveau d’alerte élevé pour lesquelles l’ajout de pictogrammes, destinés aux fournisseurs de soins de santé, permettrait de rendre l’administration de médicaments plus sécuritaire. La présente étude représentait la première étape dans l’élaboration de ces pictogrammes.</p><p><strong>Méthodes :</strong> Des professionnels qui se définissaient comme experts en gestion de médicaments ont participé à un processus Delphi modifié dans le but d’arriver à un consensus à propos des situations où des pictogrammes de sécurité doivent être ajoutés à l’étiquette afin d’optimiser la gestion sécuritaire des médicaments. L’étude a été divisée en trois phases : génération de questions de sécurité, élimination de questions de sécurité et sélection de questions de sécurité. Les questions qui atteignaient un consensus d’au moins 80 % et qui étaient considérées comme les plus essentielles ont été retenues pour des études ultérieures. Les questions de sécurité retenues ont été soumises à une analyse sémiotique, puis des ébauches de pictogrammes ont été créées.</p><p><strong>Résultats :</strong> Parmi les 87 professionnels de la santé (notamment des pharmaciens, des techniciens en pharmacie, du personnel infirmier et des médecins) invités à participer au processus Delphi, 30 ont pris part aux trois étapes. Au total, 55 situations pour lesquelles il pourrait être avantageux d’utiliser des pictogrammes de sécurité ont été générées au départ. Grâce au processus Delphi, ce nombre a été réduit à 10 situations pour lesquelles la sécurité des médicaments pourrait être accrue à l’aide de pictogrammes de sécurité. Pour la plupart des questions retenues, entre trois et six pictogrammes ont été conçus à l’aide des résultats de l’analyse sémiotique.</p><p><strong>Conclusion :</strong> Les pharmaciens, les techniciens en pharmacie, le personnel infirmier et les médecins qui ont participé à l’étude ont atteint un consensus sur dix questions au sujet de l’administration sécuritaire des médicaments pour lesquelles l’élaboration et la mise en place de pictogrammes de sécurité pourraient être avantageuses. Ensuite, des pictogrammes ont été conçus pour neuf questions au total. Dans les études ultérieures, il faudra évaluer l’efficacité des pictogrammes et s’assurer qu’ils sont interprétés correctement.</p>

scholarly journals Finding Consensus About the Level of Medication Safety in a Hospital Setting: Development and an Example of Application of a Modified Delphi Method

2021 ◽  
Vol 9 ◽  
Author(s):  
Birgit Böhmdorfer-McNair ◽  
Wolfgang Huf ◽  
Reinhard Strametz ◽  
Michael Nebosis ◽  
Florian Pichler ◽  
...  
Keyword(s):  
Delphi Method ◽  
Medication Safety ◽  
Synthesis Method ◽  
Hospital Setting ◽  
Inpatient Setting ◽  
Group Level ◽  
Safety Level ◽  
Healthcare Facilities ◽  
Information Synthesis ◽  
Level Ii

A version of the Institute for Safe Medication Practices (ISMP) questionnaire adapted to the Austrian inpatient setting was used to sample the estimates of a group of experts regarding the level of medication safety in a level II hospital. To synthesize expert opinions on a group level reproducibly, classical Delphi method elements were combined with an item weight and performance weight decision-maker. This newly developed information synthesis method was applied to the sample dataset to examine method applicability. Method descriptions and flow diagrams were generated. Applicability was then tested by creating a synthesis of individual questionnaires. An estimate of the level of medication safety in an Austrian level II hospital was, thus, generated. Over the past two decades, initiatives regarding patient safety, in general, and medication safety, in particular, have been gaining momentum. Questionnaires are state of the art for assessing medication practice in healthcare facilities. Acquiring consistent data about medication in the complex setting of a hospital, however, has not been standardized. There are no publicly available benchmark datasets and, in particular, there is no published method to reliably synthesize expertise regarding medication safety on an expert group level. The group-level information synthesis method developed in this study has the potential to synthesize information about the level of medication safety in a hospital setting more reliably than unstructured approaches. A medication safety level estimate for a representative Austrian level II hospital was generated. Further studies are needed to establish convergence characteristics and benchmarks for medication safety on a larger scale.

scholarly journals Classification as Catachresis: Double Binds of Representing Difference with Semiotic Infrastructure

2019 ◽  
Vol 44 (3) ◽  
Author(s):  
Lindsay Poirier
Keyword(s):  
Best Practices ◽  
Ethnographic Study ◽  
Double Binds ◽  
Culturally Informed ◽  
Base De Données ◽  
Infrastructure Design ◽  
Système D’Information ◽  
Insight Into

Background  This article explores the results of a three-year ethnographic study of how semiotic infrastructures—or digital standards and frameworks such as taxonomies, schemas, and ontologies that encode the meaning of data—are designed. Analysis  It examines debates over best practices in semiotic infrastructure design, such as how much complexity adopted languages should characterize versus how restrictive they should be. It also discusses political and pragmatic considerations that impact what and how information is represented in an information system.Conclusion and implications This article suggests that all databased representations are forms of data power, and that examining semiotic infrastructure design provides insight into how culturally informed conceptions of difference structure how we access knowledge about our social and material worlds.Contexte  Cet article explore les résultats d’une étude ethnographique ayant duré trois ans sur la manière de concevoir les infrastructures sémiotiques, c’est-à-dire les normes et cadres numériques tels les taxonomies, schémas et ontologies qui donnent un sens aux données.Analyse  L’article examine les débats sur les meilleures pratiques dans la conception des infrastructures sémiotiques, tels que le niveau de complexité qu’un langage adopté devrait démontrer par rapport à son caractère restrictif. Il rend compte aussi de considérations politiques et pragmatiques ayant un impact sur le choix d’informations représentées dans un système d’information et la manière de les représenter.Conclusion et implications  Cet article suggère que toute représentation dans une base de données est une utilisation de données à des fins de pouvoir, et que l’examen de la manière dont les infrastructures sémiotiques sont conçues peut nous aider à mieux comprendre comment les notions de différence informées culturellement structurent la façon dont nous appréhendons les connaissances de nos univers sociaux et matériaux. 

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