IHI.org - A resource from the Institute for Healthcare Improvement
Header Image






Reduce Adverse Drug Events Involving Insulin:
Use Pre-Printed Orders for Insulin

Correct dosing of insulin is important to ensure appropriate coverage and prevent adverse drug events (ADEs). The exact dose to be given a patient is often determined by the patient’s blood sugar level, so it is important that staff clearly understand the orders. Pre-printed orders enable a prescriber to quickly select the appropriate dosage and corresponding infusion flow rate for a given blood sugar value and to avoid the risk of misinterpreting the order due to unclear handwriting. Improving accuracy by means of pre-printed orders is extremely important when administering insulin infusions because small changes in flow rates may result in large differences in the dose administered. When using computerized prescriber order entry systems, place these orders in the computer system so prescribers can quickly make their selections on screen.


Tips
  • Work with physicians to develop one set of standardized orders for all patients, rather than having multiple versions, which increases chances for error.
  • Provide patients with a copy of the orders so they can be involved in the process and learn about their insulin.
  • Use only one standard solution for insulin infusions, and mix all solutions in the pharmacy.
  • Provide dose calculation aids on insulin infusion bags.