Challenge 3C Medication Errors

Improve Prevention of Severe Hypoglycemia

Executive Summary Checklist

Severe hypoglycemia (SH) causes significant morbidity and occasional mortality in hospitalized patients. The establishment of an effective program to reduce errors in the recognition and treatment of SH requires an implementation plan that includes the following actionable steps:

  • Establish a commitment from hospital administration and medical leadership to reduce SH.
  • Raise institutional awareness of the issue by comparing hospital and nursing units based on performance quality scorecards.
  • Create a multidisciplinary team that includes physicians, pharmacists, nurses, diabetic educators, medication safety officers, case managers, and long-term healthcare professionals. This team will:
    • Develop a system to identify patients receiving anti-diabetic medications (sulfonylureas, insulins, etc.) in the Electronic Health Record (EHR).
    • Implement real-time surveillance methods, analysis tools, and point-of-care blood glucose (BG) monitoring and reporting systems.
    • Create insulin order sets that could be modified to reduce risks of hypoglycemia.
    • Coordinate glucose monitoring, insulin administration, and meal delivery during changes of shift and times of patient transfer.
    • Develop a systematic approach to reduce SH and implement universal best practices.
  • Continuously monitor the incidence of SH in the hospital, and use the results of this monitoring in medical staff education sessions as a part of Continuous Quality Improvement (CQI).

Between the 2017 World Patient Safety, Science & Technology Summit and the 2017 Midyear Planning Meeting a workgroup comprised of experts representing administrators, clinicians, technologists and patient advocates will meet to update this APSS. If you are interested in joining this workgroup, please email us.

Parent Challenge

  1. Challenge 3: Medications