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Am J Health Syst Pharm. 2017 Dec 15;74(24):2054-2059. doi: 10.2146/ajhp160348.

Randomized controlled evaluation of an insulin pen storage policy.

Author information

Department of Pharmacy, Wake Forest Baptist Medical Center, Winston-Salem, NC
School of Nursing, University of Northern Colorado, Greeley, CO.
Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD.
Department of Medicine, Johns Hopkins Hospital, Baltimore, MD.
Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY.
Clinical Engineering Services, Johns Hopkins Hospital, Baltimore, MD.
Department of Mental Health, Department of Biostatistics, and Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD.
Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins School of Medicine, Baltimore, MD.
Translational Software, Inc., Bellevue, WA.
Department of Neurology, Division of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD.
Department of Neuroscience Nursing, Johns Hopkins Hospital, Baltimore, MD.



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.


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.


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.


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.


insulin; nurses; patient safety; policy guideline adherence

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