According to the National Action Plan for Adverse Drug Event Prevention; 2014, a nationally representative sample of inpatient Medicare beneficiaries hospitalized in 2008, identified hypoglycemia as the third most common ADE.
According to The Joint Commission on Accreditation of Healthcare Organizations 2010, on the basis of 25,145 hospital visits, in the 2004 Medicare Patient Safety Monitoring System sample, an estimated 10.7% of patients exposed to insulin/hypoglycemic agents experience associated ADE.
The Institute for Safe Medication Practice (ISMP) has identified insulin as an inpatient high-alert medication. Data indicate that approximately one-quarter of all patient safety incidents involving insulin resulted in patient harm, and insulin may be implicated in 33 percent of medication error–related deaths1, 2, 3, 4, 5, 6. Insulin-related medication errors have been reported across all units of the hospital and can occur at multiple stages of the medication use process, with the majority of errors occurring at the time of prescribing and administration 1, 2, 2, 4, 5, 6.
Effective prevention of inpatient diabetes agent adverse events requires multidisciplinary coordination. A systematic approach is essential to promoting the safe and appropriate use of insulin in inpatient settings, because medication errors can occur at multiple stages in the medication process. Rural Facilities will focus on reducing harm and preventing ADE’s from hypoglycemic agents in the rural communities they serve.
1 Institute for Safe Medication Practices. ISMP’s list of high-alert medications. Available from: http://www.ismp.org/tools/highalertmedicationLists.asp. Accessed February 22, 2013. 22.
2 Lewis AW, Bolton N, Mcnulty S. Reducing inappropriate abbreviations and insulin prescribing errors through education. Diabet Med. 2010;27(1):125-6.
3 Cousins D, Rosario C, Scarpello J. Insulin, hospitals and harm: a review of patient safety incidents reported to the National Patient Safety Agency. Clin Med. 2011;11(1):28-30.
4 Hellman R. A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocr Pract. 2004;10 Suppl 2:100-8.
5 Deal EN, Liu A, Wise LL, Honick KA, Tobin GS. Inpatient insulin orders: are patients getting what is prescribed? J Hosp Med. 2011;6:526-9.
6 Cobaugh DJ, Maynard G, Cooper L, Kienle PC, Vigersky R, Childers D, et al. Enhancing Insulin-Use Safety in Hospitals: Practical Recommendations from an American Society of Health Systems Pharmacists (ASHP) Foundation Expert Consensus Panel. Amer Society Health-Syst Pharm. 2013;70:e18-27.
Tools and Resources
- Action Bundle
- Hypoglycemic Strategy
- Patient and Family Engagement
- Adverse Drug Event Prevention | Test of Change Template
- Planning an Intervention Job Aid | ADE Prevention
- ADE Anticoagulant Safety | Top Ten Checklist
- ADE Opioid Overdose Prevention – Hospital Setting
- ADE Hypoglycemic Agents – Top Ten Checklist