{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T01:56:27Z","timestamp":1790560587230,"version":"4.1.0"},"reference-count":10,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T00:00:00Z","timestamp":1787788800000},"content-version":"am","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>High-alert medications such as insulin pose serious risks to patients when used in error. In response to vulnerabilities identified in existing insulin administration workflows, we implemented a comprehensive approach to mitigate the risk of errors in the hospital setting.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Summary<\/jats:title>\n                    <jats:p>A new electronic health record capability, referred to as the \u201ctriple-scan system,\u201d was introduced to enhance insulin pen administration safety. This system requires nurses to scan the patient\u2019s wristband barcode, the insulin pen manufacturer\u2019s barcode, and the pharmacy\u2019s linking label barcode applied to the pen before it is retrieved from an automated dispensing machine. Other measures were also implemented to prevent errors, including a 2-nurse verification process and visual aids. A performance dashboard was used to track insulin pen administration. After the triple-scan system was integrated into workflows, the performance dashboard showed increasing numbers of barcodes scanned over a period of 4 months, whereas the number of unscanned barcodes remained low. Postimplementation surveys of 174 nurses indicated high satisfaction with the new system, with 67% (n = 116) reporting improved patient safety and 71% (n = 124) finding it user friendly.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>The triple-scan system ensures the use of a single insulin pen for each patient, which may enhance patient safety by helping to prevent exposure to blood-borne pathogens. Engaging nurses as essential stakeholders and providing ongoing support and training were critical to the success of this intervention. Continuous monitoring and improvements are necessary to ensure the long-term sustainability of the triple-scan system.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/ajhp\/zxag247","type":"journal-article","created":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T20:46:16Z","timestamp":1787863576000},"source":"Crossref","is-referenced-by-count":0,"title":["Improving patient safety with triple-scan technology for insulin pen administration"],"prefix":"10.1093","author":[{"given":"Courtney K","family":"Wulffson","sequence":"first","affiliation":[{"name":"Pharmacy Services, Mayo Clinic Health System in Northwest Wisconsin , Eau Claire, WI ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Melissa M","family":"Babin","sequence":"additional","affiliation":[{"name":"Department of Nursing, Mayo Clinic Health System in Northwest Wisconsin , Eau Claire, WI ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Merissa T","family":"Andersen Pinotti","sequence":"additional","affiliation":[{"name":"Pharmacy Services, Mayo Clinic , Rochester, MN ,","place":["USA"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,8,27]]},"reference":[{"key":"2026092721465504100_zxag247-B1","author":"Institute for Safe Medication Practices"},{"key":"2026092721465504100_zxag247-B2","author":"Food and Drug Administration"},{"key":"2026092721465504100_zxag247-B3","author":"Food and Drug Administration"},{"key":"2026092721465504100_zxag247-B4","author":"Centers for Disease Control and Prevention"},{"issue":"16","key":"2026092721465504100_zxag247-B5","doi-asserted-by":"publisher","first-page":"1404","DOI":"10.2146\/ajhp130169","article-title":"Enhancing insulin-use safety in hospitals: practical recommendations from an ASHP Foundation expert consensus panel","volume":"70","author":"Cobaugh","year":"2013","journal-title":"Am J Health-Syst Pharm"},{"key":"2026092721465504100_zxag247-B6","doi-asserted-by":"publisher","first-page":"7951","DOI":"10.1211\/PJ.2021.1.95382","article-title":"Hospital insulin errors remain high, but we can improve the safety of inpatients with diabetes","volume":"307","author":"Bain","year":"2024","journal-title":"Pharmaceut J"},{"issue":"24","key":"2026092721465504100_zxag247-B7","doi-asserted-by":"publisher","first-page":"2054","DOI":"10.2146\/ajhp160348","article-title":"Randomized controlled evaluation of an insulin pen storage policy","volume":"74","author":"Gibbs","year":"2017","journal-title":"Am J Health-Syst Pharm"},{"issue":"12","key":"2026092721465504100_zxag247-B8","doi-asserted-by":"publisher","first-page":"814","DOI":"10.1016\/j.jcjq.2019.09.002","article-title":"Is one-pen, one-patient achievable in the hospital? A quality improvement project to reduce risks of inadvertent insulin pen sharing at a large academic medical center","volume":"45","author":"Ho","year":"2019","journal-title":"Jt Comm J Qual Patient Saf"},{"issue":"5","key":"2026092721465504100_zxag247-B9","doi-asserted-by":"publisher","first-page":"380","DOI":"10.1016\/j.jcjq.2018.08.006","article-title":"Development and implementation of a subcutaneous insulin pen label bar code scanning protocol to prevent wrong-patient insulin pen errors","volume":"45","author":"MacMaster","year":"2019","journal-title":"Jt Comm J Qual Patient Saf"},{"issue":"12","key":"2026092721465504100_zxag247-B10","doi-asserted-by":"publisher","first-page":"986","DOI":"10.1136\/bmjqs-2015-004411","article-title":"SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): revised publication guidelines from a detailed consensus process","volume":"25","author":"Ogrinc","year":"2016","journal-title":"BMJ Qual Saf"}],"container-title":["American Journal of Health-System Pharmacy"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/ajhp\/advance-article-pdf\/doi\/10.1093\/ajhp\/zxag247\/70822609\/zxag247.pdf","content-type":"application\/pdf","content-version":"am","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/ajhp\/advance-article-pdf\/doi\/10.1093\/ajhp\/zxag247\/70822609\/zxag247.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T01:47:03Z","timestamp":1790560023000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/ajhp\/advance-article\/doi\/10.1093\/ajhp\/zxag247\/8772128"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,27]]},"references-count":10,"URL":"https:\/\/doi.org\/10.1093\/ajhp\/zxag247","relation":{},"ISSN":["1079-2082","1535-2900"],"issn-type":[{"value":"1079-2082","type":"print"},{"value":"1535-2900","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,27]]},"article-number":"zxag247"}}