Safety Concerns With Insulin Use in the Inpatient Setting: The Pharmacist’s Role

Key Points

  • Insulin is the most appropriate agent for the majority of hospitalized patients.

  • Insulin is a “high-alert medication.”

  • For effective and safe use of insulin, institutions need to consider:
    • Standardized pharmacy operations
    • Education of nursing and support staff
    • Implementation of hospital-wide initiatives
    • Effective communication and collaboration among caregivers

Suggested Reading

Clinical Guidelines and Medication Alerts

American Society of Health-System Pharmacists and the Hospital and Health System Association of Pennsylvania. Professional practice recommendations for safe use of insulin in hospitals. 2004.

Institute for Safe Medication Practices. ISMP’s list of high-alert medications. 2012.

Joint Commission. ‘High-alert’ medications and patient safety. Int J Qual Health Care. 2001;13:339-340.

Joint Commission. Advanced certification in inpatient diabetes.

Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15:353-369.

Pennsylvania Patient Safety Advisory. Complexity of insulin therapy. PA PSRS Patient Saf Advis. 2005;2:30-31.

Society of Hospital Medicine. The case for supporting inpatient glycemic control programs now: the evidence and beyond. 2008.

Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012;97:16-38.

Additional Reading

Ahmann AJ, Maynard G. Designing and implementing insulin infusion protocols and order sets. J Hosp Med. 2008;3:42-54.

Bailon RM, Partlow BJ, Miller-Cage V, et al. Continuous subcutaneous insulin infusion (insulin pump) therapy can be safely used in the hospital in select patients. Endocr Pract. 2009;15:24-29.

Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553-591.

Cohen MR. Pharmacists' role in ensuring safe and effective hospital use of insulin. Am J Health Syst Pharm. 2010;67:S17-21.

Cyrus RM, Szumita PM, Greenwood BC, et al. Evaluation of compliance with a paper- based, multiplication-factor, intravenous insulin protocol. Ann Pharmacother. 2009;43:1413-1418.

Flanders SJ, Juneja R, Roudebush CP, et al. Glycemic control and insulin safety: the impact of computerized intravenous insulin dosing. Am J Med Qual. 2009;24:489-497.

Foster JJ, Pitts W. Implementation of an insulin therapy protocol: applying the Baldrige approach. Am J Health Syst Pharm. 2009;66:1035-1038.

Hassan E. Hyperglycemia management in the hospital setting. Am J Health Syst Pharm. 2007;64:S9-S14.

Hellman R. A systems approach to reducing errors in insulin therapy in the inpatient setting. Endocr Pract. 2004;10(suppl 2):100-108.

Hermayer KL, Cawley P, Arnold P, et al. Impact of improvement efforts on glycemic control and hypoglycemia at a university medical center. J Hosp Med. 2009;4:331-339.

Juneja R, Roudebush CP, Nasraway SA, et al. Computerized intensive insulin dosing can mitigate hypoglycemia and achieve tight glycemic control when glucose measurement is performed frequently and on time. Crit Care. 2009;13:R163.

Kelly JL. Ensuring optimal insulin utilization in the hospital setting: role of the pharmacist. Am J Health Syst Pharm. 2010;67:S9-16.

Kirk JK, Oldham EC. Hyperglycemia management using insulin in the acute care setting: therapies and strategies for care in the non-critically ill patient. Ann Pharmacother. 2010;44:1222-1230.

Lee A, Faddoul B, Sowan A, Johnson KL, Silver KD, Vaidya V. Computerisation of a paper-based intravenous insulin protocol reduces errors in a prospective crossover simulated tight glycaemic control study. Intensive Crit Care Nurs. 2010;26:161-168.

Magee M. Hospital protocols for targeted glycemic control: development, implementation and models for cost justification. Am J Health-System Pharm. 2007;64:S15-S20.

Maynard G, Lee J, Phillips G, et al. Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: effect of structured subcutaneous insulin orders and an insulin management algorithm. J Hosp Med. 2009;4:3-15.

Moghissi ES. Important updates on the management of inpatient hyperglycemia: practical implications for pharmacists. Introduction. Am J Health Syst Pharm. 2010;67:S2.

Moghissi ES. Insulin strategies for managing inpatient and outpatient hyperglycemia and diabetes. Mt Sinai J Med. 2008;75:558-566.

Murphy DM, Vercruysse RA, Bertucci TM, et al. Reducing hyperglycemia hospitalwide: the basal-bolus concept. Jt Comm J Qual Patient Saf. 2009;35:216-223.

Noschese M, Donihi AC, Koerbel G, et al. Effect of a diabetes order set on glycaemic management and control in the hospital. Qual Saf Health Care. 2008;17:464-468.

Rea RS, Donihi AC, Bobeck M, et al. Implementing an intravenous insulin infusion protocol in the intensive care unit. Am J Health Syst Pharm. 2007;64:385-395.

Samaan KH, Dahlke M, Stover J. Addressing safety concerns about U-500 insulin in a hospital setting. Am J Health Syst Pharm. 2011;68:63-68.

Schmeltz LR, DeSantis AJ, Schmidt K, et al. Conversion of intravenous insulin infusions to subcutaneously administered glargine in patients with hyperglycemia. Endocr Pract. 2006;12:641-650.

Szumita PM. The hospital pharmacist: an integral part of the hyperglycaemic management team. J Clin Pharm Ther. 2009;34:613-621.

Thompson R, Schreuder AB, Wisse B, et al. Improving insulin ordering safely: the development of an inpatient glycemic control program. J Hosp Med. 2009;4:E30-E35.

Vivian EM. The pharmacist's role in maintaining adherence to insulin therapy in type 2 diabetes mellitus. Consult Pharm. 2007;22:320-332.

Weant KA, Ladha A. Conversion from continuous insulin infusions to subcutaneous insulin in critically ill patients. Ann Pharmacother 2009;43:629-634.