Orlando, Fla.—The American Society of Health-System Pharmacists (ASHP) Foundation has issued 10 clinical recommendations it believes can substantially reduce the incidence of in-hospital insulin-related adverse events (AEs) if implemented.
The strategies, which target errors during all stages of insulin use, “have several strong advantages,” said Joshua Neumiller, PharmD, CDE, an assistant professor in the Department of Pharmacotherapy at Washington State University’s College of Pharmacy in Spokane. “One thing is that they [the recommendations] stress the need for standardized, evidence-based, protocol-driven order sets for insulin use and they also recommend transitioning from reactive to proactive glycemic management approaches,” commented Dr. Neumiller, who was not involved in developing the recommendations.
Other organizations have published safe insulin-use guidelines (J Clin Endocrinol Metab 2012;97:16-38; ACE/ADA Task Force consensus statement Endocr Pract 2006;12[suppl 3]:4-13). Nevertheless, insulin-related AEs remain unacceptably high, according to Daniel Cobaugh, PharmD, lead author of the recommendations and vice president of the ASHP Research and Education Foundation, in Bethesda, Md. To develop these new recommendations, the ASHP Foundation commissioned the Institute for Safe Medication Practices (ISMP) to review the published literature and the ISMP National Medication Error Reporting Program to identify in-hospital insulin-use errors. Based on the findings, Dr. Cobaugh and his colleagues generated a 60-item survey, which they disseminated to a 21-member panel asked to rank the three highest-priority errors they thought should be addressed (Table).
Dr. Cobaugh said the broadly representative panel—including pharmacists, physicians, nurses and consumer advocacy groups—will help drive adoption of the recommendations. “This is the first time an interprofessional panel has issued insulin safety use recommendations,” he stressed.
The 10 recommendations were developed from the panel’s input and include the following:
- In both computerized prescriber order entry systems and paper medical record systems, replace the use of free-text insulin orders with evidence-based, protocol-driven order sets for specific insulin uses. The sets should include guidance for glucose monitoring and decision support, and should take into consideration a patient’s nutritional status (see the American Association of Clinical Endocrinologists’ Diabetes Resource Center for sample order sets at http://inpatient.aace.com/protocols-and-order-sets).
- Eliminate routine administration of sliding-scale insulin doses as a primary treatment strategy for hyperglycemia.
Storing and Dispensing
- Store only U-100 concentration insulin, and ensure the insulin and administration devices kept in patient care areas are securely stored. There have been cases in which U-500 insulin was inadvertently used instead of U-100 insulin, leading to a fivefold increase in insulin concentrations and severe hypoglycemia (Am J Health Syst Pharm 2011;68:63-68). Additionally, there have been reports of insulin being confused with other medications such as heparin (see, e.g., Pennsylvania Patient Safety Authority Pa Patient Saf Advis 2010;7:9-17).
- Develop hospital-wide standard concentrations for insulin infusions. “There can be confusion and errors if concentrations are not standardized,” Dr. Cobaugh explained.
- Because insulin infusions prepared by clinicians potentially can be diluted to incorrect or nonstandard concentrations, leading to medication errors, limit preparation of bolus and infusion insulin to the pharmacy.
- Develop policies and procedures and provide staff education to ensure insulin pens are not reused in multiple patients. Pens have been found to contain blood cells and tissue following a single use, and therefore present an infection risk if reused in another patient. Both the FDA and the ISMP have warned of this risk (see “Information for healthcare professionals: risk of transmission of blood-borne pathogens from shared use of insulin pens” at www.fda.gov and the ISMP’s “Reuse of insulin pen for multiple patients risks transmission of bloodborne disease” at www.ismp.org).
- Ensure insulin use is linked to a patient’s nutritional status and coordinate meal delivery, point-of-care glucose testing and insulin administration in a standardized fashion.
- Educate patients and their caregivers to request rapid-acting insulin at the beginning of a meal, because administering rapid-acting insulin along with meals decreases the risk for insulin-related hypoglycemia.
- In patients with variable nutritional intake, delay administration of prandial insulin until meals are completed.
- Develop protocol-driven and evidence-based order sets for insulin use and blood glucose monitoring for use specifically during enteral (EN) and parenteral nutrition (PN) interruptions (see J Hosp Med 2009;4:3-15 for EN- and PN-specific order sets).
- Prospectively document hypoglycemia and hyperglycemia rates. Monitor insulin use, coordinated insulin administration, glucose testing and nutritional delivery. The Surgical Care Improvement Project (http://www.jointcommission.org/surgical_care_improvement_project) and the Partnership for Patients (partnershipforpatients.cms.gov) are two collaborations that provide national quality measure outcomes for comparison.
- Provide real-time, hospital-wide glucose reports to health care teams to ensure appropriate surveillance and management of patients with unexpected hypoglycemia (blood glucose ≤40 mg/dL) and hyperglycemia (blood glucose ≥180 mg/dL).
- Provide standardized education, including competency assessments, to all hospital-based health professionals responsible for insulin use.
Gregory A. Maynard, MD, MSc, who co-authored the recommendations and presented them at the ASHP 2013 Midyear Clinical Meeting, said the recommendations include a heavy emphasis on physician insulin prescribing as well as nursing care. “We found some of the most common causes of insulin-related errors were inappropriate prescribing, failure to adjust insulin dosing in response to unexpected nutrition interruption and mismatch between carbohydrate intake and insulin intake,” said Dr. Maynard, who is the director of the Center for Innovation and Improvement Science at the University of California, San Diego. He added that caregivers also need to improve how and when they assess initial insulin events.
“We don’t do a good enough job at looking at why hypoglycemia occurs, and this doesn’t allow us to deter recurrences,” Dr. Maynard said.
Scott Mathis, PharmD, the director of pharmacy at Monmouth Medical Center in Long Branch, N.J., applauded the guidelines for being “more focused on safety than previous guidelines.
“They use an objective and structured approach based on tracking and trending of actual adverse events,” said Dr. Mathis, who was not involved in the development of the recommendations.
“One thing I like is that they allow use of insulin pens in hospital,” he said. “In my experience, having nurses draw up doses from vials in syringes leads to a large potential for errors, especially 10-fold dosing errors due to incorrect volume being drawn up.”
The recommendations were also published in the ASHP journal earlier in 2013 (Am J Health Syst Pharm 2013;70:1404-1413).
Dr. Cobaugh reported receiving funding from Sanofi for the development of the recommendations. Drs. Maynard, Mathis and Neumiller reported no relevant conflicts of interest.
Highest-Priority Insulin Errors×
- Incorrect dosage/irrational orders
- Nomenclature-related errors
- Incorrect transcription of verbal or telephone orders
- Transcription of incorrect dose
- Failure to double-check insulin products before administration
- Confusion with look-alike containers
- Unsecure storage in patient care and pharmacy areas
- Administration of incorrect doses
- Incorrect use of insulin pens
- Failure to match insulin to nutritional status or intake
- Failure to appropriately monitor for insulin effects and adjust dose accordingly
× List not in order of priority