Diabetic patients who use insulin are at risk of suffering adverse drug events (ADEs) if their insulin care is not carefully managed. Hypoglycemic episodes can be sudden and severe and may lead to other complications and harm. Coordinating care processes so as to properly time monitoring of glucose levels and administration of insulin can help reduce the risk of an ADE. Using standardized tools for dosing insulin and testing blood sugar levels also can help to reduce such events.

Changes for Improvement

Use Diabetic Management Flowsheets

Keeping all information regarding management of a diabetic patient’s condition organized in one place helps clinical staff in assessing and planning therapy. A flowsheet is a great way for staff to record orders, doses administered, flow rates, lab values, and other important information. It also helps prescribers, who may wish to review the flowsheet when assessing a patient’s response to therapy or when considering order changes. Using a comprehensive flowsheet means that staff will not have to search through a patient record or look in several different places for the information they need.

Tips 

• In the flowsheet, incorporate guidelines or protocols that may be in use. 
• Include dose calculation aids for insulin infusions. 
• Organize blood glucose information so that results over time can be seen, not just the most recent result.

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.

Permit Patients to Self-Administer Insulin

Many patients on insulin have been administering their own doses at home quite successfully for some time prior to their hospital admission. Yet, once in the hospital, we often take this responsibility away from them, only to give it back again at discharge. Involve patients in their own care by having them administer their own insulin while in the hospital if they feel comfortable doing so. Not only does this serve as an excellent opportunity to verify patients’ understanding of their medications and provide education, but it also helps prevent adverse drug events. Timeliness of insulin administration is important in preventing adverse drug events. Patients have the most at stake in making sure that their medications are administered correctly and on time and therefore are likely to try to do it correctly. Since patients have only their own medications to administer, they may have a better chance of doing so on time than busy nursing staff might.

Tips 

• Encourage patients who are experienced in doing so at home to administer their own medications while in the hospital, but don’t force the issue. If the patient is uncomfortable with the idea, it may be best not to take this course. 
• Encourage patients for whom insulin is newly prescribed to administer their own doses while in the hospital so they will become competent in doing so before they go home. Supervise administration to verify the patient’s understanding. 
• Have the parents of pediatric patients administer medications to their children as long as it is appropriate and they are comfortable with the idea. 
• Remember that older pediatric patients (not babies or toddlers) like to be included in their care and have a role, so consider ways for them to be involved in self-medication with appropriate supervision. This is particularly important for children with chronic illnesses. 
• Ensure that there is a good recording system in place to accurately capture information about doses that patients have administered themselves. Consider a patient-maintained medication administration record. 
• Re-assess patients regularly to ensure that they are still appropriate for self-medication, as their clinical condition and some therapies may affect their ability to do this well.

Perform Glucose Monitoring on Patient Care Units

Monitoring of diabetic patients and determining their insulin doses both depend on measurement of blood sugar levels. Using equipment to measure the blood glucose level directly on the patient care unit gives the results more rapidly than waiting for results when samples are sent to a laboratory. This helps staff provide treatment in a more timely fashion, which helps prevent adverse drug events resulting such as those that would result from hypoglycemia or hyperglycemia. 

Tips

• Make sure that the unit has a quality assurance program for testing and coordinates it with that of the main laboratory. 
• Evaluate staff competence regularly to minimize errors with measurement and interpretation of blood glucose levels.
• Include patients in the process, as they may need to learn how to measure their own blood glucose at home.

Coordinate Insulin Doses with Meal Times

If there is a long delay between administration of a dose and the time when the patient eats, the patient may suffer an adverse drug event related to hypoglycemia. Coordinating the dosing time with meal delivery times in the hospital setting can prevent this outcome. 

Tips

• Confirm that the patient has eaten, just in case there was a delay in meal delivery or the patient did not eat. 
• Consider having patients in hospital administer their own insulin (if they are accustomed to doing so at home or are learning how), so they can coordinate the dose with the time that they eat. 
• Keep food available on the patient care unit so that patients can eat even if there is a long delay in meal delivery.

Use Timed Alarms and Electronic Reminders for Insulin Administration

Consistent timing of doses is important with insulin to minimize the risk of an adverse drug event. However, when staff are busy, it is easy to miss an administration time. A timed alarm or reminder from a clock or other electronic device can remind staff when a patient’s next insulin dose is due so that medication is administered on time. Just make sure that the devices are placed where staff will hear or see the timer alarm.

Tips

• Involve patients in consistent timing of doses by placing a clock with a timer at each patient’s bedside and asking the patient to alert the staff when the dose is due. 
• Choose timer alarms that are different from other alarm devices on the unit so that the sound or other means of alarm is unique and easily identified. 
• Remember that audible alarms can add to the noise level on the unit, which can make it difficult for staff to concentrate and patients to rest. Consider using visual alarms or pagers that vibrate instead. 
• Place the alarm or timer near the point of care so that staff must be near the patient to turn it off. Ideally, staff turn off the alarm simultaneously to administering the drug, not before. 
• Use patient self-medication to improve timeliness of administration, since many patients on insulin were accustomed to administering their own doses at home.