Adverse Glycemic Events and Critical Emergencies
Problem: On For years, insulin errors have been linked to harmful adverse events, often resulting in serious hypoglycemia or hyperglycemia. Glycemic management in patients with diabetes and/or the acutely ill who are receiving insulin can be challenging, especially since the frequency and timing of necessary blood glucose assessments are often patient specific. Furthermore, communication breakdowns; inaccurate home medication lists; untimely medication reconciliation; insulin mix-ups; and delays in assessments, nutritional intake, and initiation of glycemic management protocols, may lead to a critical medical emergency and can also complicate care during such emergencies.
To further investigate these situations, ECRI and the Institute for Safe Medication Practices (ISMP) Patient Safety Organization (PSO) analyzed 100 adverse glycemic events reported to the PSO between May 2018 and April 2020 that led to or occurred during a critical medical emergency, such as a rapid response team call or a cardiopulmonary arrest. All of the analyzed events fell within category E (temporary harm) through I (death) according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for Categorizing Medication Errors. The key contributing factors, along with a few examples of the reported errors, are summarized below.
Key Contributing Factors
Omissions or delays in initiating glycemic management protocols. In approximately 30% of the analyzed events, hypoglycemia and hyperglycemia management protocols did not exist, were not ordered, or were not initiated when indicated, leading to a failure in addressing blood glucose values below or above normal limits. In some cases, prescribers were unaware of low or high blood glucose levels, and a glycemic management protocol and/or treatment was not initiated until the patient’s condition deteriorated.
The blood glucose level of an unresponsive hospitalized patient with a history of hypoglycemia was checked using a glucose meter and was found to be 55 mg/dL. The patient failed to respond to repeated attempts to arouse her, including a sternal rub, so a rapid response team was called. Still unresponsive, the patient was transferred to a critical care unit. However, a glycemic management protocol was never initiated, and treatment with a rescue agent (intravenous [IV] dextrose) was not provided. Additionally, no further measurement of the patient’s blood glucose was ordered or obtained.
Medication administration issues. Administration issues caused by look-alike insulin names or label mix-ups and/or knowledge deficits accounted for approximately 25% of the analyzed glycemic events. A few errors were associated with documentation issues or too-rapid administration of an IV 50% dextrose solution leading to infiltration and phlebitis. However, most administration-related errors involved giving the wrong type of insulin (long-acting vs. short-acting), the wrong dose of insulin, or the wrong drug (i.e., administering insulin instead of the prescribed medication).
Insulin administered without consideration of dietary intake. Nearly 20% of the analyzed events were associated with patients receiving their usual full dose of insulin despite being NPO or unable to consume a meal in a timely manner after receiving insulin. More than half of these patients were prescribed prandial (meal-related) and basal (long-acting) insulin, but the doses were not adjusted to account for their dietary intake.
A rapid response team was called to the bedside of an unresponsive patient who was seizing. The patient’s point-of-care blood glucose was only 23 mg/dL at that time. A nurse began administering a 50% dextrose solution IV, and within 3 minutes, the patient was alert and her blood glucose was 100 mg/dL. The patient had received her prandial insulin (11:00 a.m.) more than 2.5 hours before lunch arrived on the unit. The patient was then encouraged to eat a full lunch.
Omissions or delays in monitoring patients. In nearly 15% of the analyzed events, healthcare practitioners failed to order blood glucose monitoring when it was indicated, failed to perform (or document) blood glucose monitoring despite specific orders, or were never notified regarding critical blood glucose values.
A rapid response team was called for a patient with diabetes with hypoxic respiratory failure. The patient was treated with oxygen supplementation and 10% dextrose solution IV and then transferred to an intensive care unit, where no point-of-care glucose monitoring was ordered or performed. The next day, the patient’s laboratory blood glucose value was 62 mg/dL in the morning and 33 mg/dL in the afternoon; however, the attending physician was never notified by the laboratory or the primary care nurse of the critically low glucose value of 33 mg/dL, and the patient was never treated. Several days later, when the patient experienced a cardiopulmonary arrest, a venous blood glucose was drawn which was 30 mg/dL. The patient became totally unresponsive and was placed on life support.
Home medication history and reconciliation errors. Six percent of the events were related to errors associated with obtaining an accurate list of home medications used for glycemic management upon hospital admission, or untimely medication reconciliation. In one event, medication reconciliation and prescribing of a new patient’s antidiabetic medications taken at home did not occur until 24 hours after admission. These events resulted in suboptimal glucose management during hospitalization or upon discharge.
A patient taking insulin at home was hospitalized for an unrelated condition. During hospitalization, he was switched to oral antidiabetic medications with positive glycemic outcomes. The attending physician prescribed these oral medications upon discharge, intending for the patient to discontinue the insulin. Because medication reconciliation did not occur at discharge, the patient did not know to stop taking insulin. The patient continued taking insulin at home, as well as his newly prescribed oral antidiabetic medications, resulting in significant hypoglycemia and hospital readmission.
Other contributing factors. A few (4%) of the analyzed events were related to other contributing factors. These included glycemic management processes that had not been clearly established, such as failing to address the possibility of hypoglycemia in patients receiving IV insulin for a PET (positron emission tomography) scan viability study. Another contributing factor included rescue medications that were unavailable due to shortages.
Safe Practice Recommendations: Based on the contributing factors uncovered during our analysis of adverse glycemic events, implement the following best practices:
Develop glycemic management protocols. Establish standard protocols and/or order sets to guide the treatment and monitoring of clinically significant hypoglycemia and hyperglycemia, including hyperosmolar hyperglycemic state and diabetic ketoacidosis.
Ensure rescue agents are available. Ensure appropriate rescue agents (e.g., juice, glucose gel, glucagon, 10% or 50% dextrose) are readily available to clinicians, with directions for when to use each rescue agent, proper administration to treat adverse glycemic events, and follow-up. During shortages, suitable alternatives should be available.
Take steps to avoid insulin mix-ups. Limit the number of different types of insulin on the formulary, and avoid close storage of medications with look-alike names or labeling/packaging. Display both the generic and brand names of insulin products on computer screens, labels, and any other format used to communicate the drug names in the facility. Also, use tall man lettering with bolded text for the unique letter characters of look-alike insulin names (e.g., HumaLOG and HumuLIN; NovoLOG and NovoLIN) when displayed in computer order entry systems, order sets, protocols, guidelines, medication administration records, automated dispensing cabinet (ADC) screens, infusion pump screens, drug storage bins, and hospital pharmacy labels.
Dispense hyperkalemia kits. Have the pharmacy dispense a hyperkalemia kit to patient care units, which includes a 3 mL vial of regular insulin (or a standard rapid-acting insulin); alcohol swabs; 50% dextrose injection; an insulin syringe that allows needleless IV administration; directions for preparation, administration, and patient monitoring requirements; and a label for the syringe (to apply after preparation but before administration).
Upon Patient Admission
Obtain the best possible medication history. Carry out a good faith effort to capture a thorough and comprehensive medication history upon admission. Verify the medications, doses, indications, and adherence to medications on the patient’s home medication list using multiple resources (e.g., outpatient pharmacy records, prior admission documentation, discharge history, interview of family members, review of actual medication containers). Always actively involve the patient and/or caregiver, if possible.
Ensure timely medication reconciliation. Require a verified home medication list, medication reconciliation, and the prescribing of necessary home medications as soon as possible after hospital admission.
Hypoglycemia and hyperglycemia risk assessment. Require the admitting nurse to conduct a risk assessment of all patients receiving insulin upon admission and periodically thereafter to identify individuals at high risk for developing hypoglycemia (e.g., low body weight, basal insulin dose greater than 0.25 units/kg, basal insulin-only dosing, concomitant oral antidiabetic medications, history of hypoglycemia) or hyperglycemia (e.g., infection, pancreatitis, trauma, alcohol abuse), and specifically target these patients for preventative interventions.
Prescribe needed blood glucose monitoring. For patients with diabetes mellitus or requiring critical care or procedures, assess the patient’s need for point-of-care or venous blood glucose monitoring and assessments, and order these as needed. Ensure the electronic health record (EHR) compiles any orders for glucose monitoring and assessments in one designated place so it is accessible to all clinicians. Discuss blood glucose monitoring results during patient care rounds and during staff communications.
Initiate protocols. Initiate glycemic management protocols/order sets for all patients with diabetes mellitus, non-diabetes critical care patients receiving insulin, and/or any patient who experiences a point-of-care or venous blood glucose value above or below a specific target value.
Coordinate meal delivery. In conjunction with meal delivery, develop a coordinated process to promote timely blood glucose checks (no longer than 1 hour before meal delivery, 0 to 30 minutes is preferred) and administration of prandial insulin (within 15 minutes of the start of a meal).
Assess nutrient intake before insulin administration. Before insulin administration, require practitioners to assess the patient’s nutrient intake, including the time and the amount eaten at the last meal, and the timing of the next meal. Consider using a system of alerting the dietary staff (e.g., colored menus) to monitor meal consumption and/or to notify a nurse when delivering a tray to a patient receiving prandial insulin.
Assess nutrient intake for changes in eating. Establish a standardized process to alert an authorized prescriber regarding any significant changes in a patient’s carbohydrate intake, which may require an adjustment of the usual insulin doses. Insulin doses, including prandial and basal doses, should only be held or modified with a prescriber’s order or via explicit directions in an existing protocol or order set.
Employ barcode scanning. Utilize bedside barcode scanning technology prior to drug administration to verify the drug and patient.
Centralize information. Ensure all patient-specific, diabetes care-related information, including blood glucose values and significant changes in carbohydrate intake (e.g., NPO status, changes in enteral or parenteral nutrition), is located in one designated place within the patient’s EHR so it is accessible to all clinicians. This may involve collaboration with your respective EHR vendor and informatics staff.
Communicate critical blood glucose values. Define clinically significant hypoglycemia parameters in terms of symptoms and blood glucose levels at which prescribers should be notified. Also, establish critical blood glucose values at which the laboratory staff are required to notify a specified practitioner (e.g., primary care nurse, prescriber).
Managing Glycemic Events
Permit emergency treatment. Establish protocols and/or coupled order sets that permit the emergency administration of an appropriate rescue agent by a qualified clinician for clinically significant hypoglycemia based on identified symptoms and/or a specified minimum blood glucose level. Investigate and track the use of rescue agents as a potential opportunity to improve overall glycemic control.
Treatment of clinical symptoms. Provide care to patients based not only on their venous or point-of-care blood glucose values, but also according to their clinical symptoms and preexisting conditions, even when their symptoms are inconsistent with a current blood glucose value.
Reassessment. Establish a minimum and maximum blood glucose value (point-of-care or venous) that prompts a prescriber to conduct a patient, nutrition, and drug therapy reassessment to determine if modification of the diet and/or glycemic management treatment is warranted. If a pattern above or below the established blood glucose values occurs, consider requiring a team of prescribers, nurses, pharmacists, and dietitians to conduct the reassessment in a collective manner.
Consultation. For patients with uncontrolled hyperglycemia or hypoglycemia, consider consulting an endocrinologist or clinician trained in diabetes or insulin management.
Educate the patient. Upon discharge, educate patients/caregivers about any changes in their pre-hospitalization home medication list, highlighting discontinued or newly prescribed medications.
Additional recommendations. The ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults can be accessed for additional recommendations to help prevent insulin errors and improve patient outcomes