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Qual Saf Health Care. 2006 Apr;15(2):89-91.

Use of a standardized protocol to decrease medication errors and adverse events related to sliding scale insulin.

Author information

1
University of Pittsburgh, 302 Scaife Hall, 200 Lothrop Street, Pittsburgh, PA 15213, USA. calabresea@upmc.edu

Abstract

PROBLEM:

Sliding scale insulin (SSI) is frequently used for inpatient management of hyperglycemia and is associated with a large number of medication errors and adverse events including hypoglycemia and hyperglycemia.

DESIGN:

Observational before and after study evaluating the impact of implementation of a standardized SSI protocol and preprinted physician order form.

SETTING:

University Hospital in Pittsburgh, PA, USA.

STRATEGY FOR CHANGE:

Guidelines for the use of SSI were created by an interdisciplinary committee and implemented in non-intensive care units. In addition, a preprinted physician order sheet was developed which included the guidelines and an option for ordering one of three standardized insulin sliding scales or a patient specific scale. EFFECT OF CHANGE: One year after implementation the physician order form was used for 91% of orders and, overall, 86% of SSI orders followed the guidelines. The number of prescribing errors found on chart review was reduced from 10.3 per 100 SSI patient-days at baseline to 1.2 at 1 year (p = 0.03). The number of hyperglycemia episodes 1 year after implementation decreased from 55.9 to 16.3 per 100 SSI patient-days.

LESSONS LEARNT:

The protocol was readily accepted by hospital staff and was associated with decreased prescribing errors and decreased frequency of hyperglycemia.

PMID:
16585106
PMCID:
PMC2464821
DOI:
10.1136/qshc.2005.014381
[Indexed for MEDLINE]
Free PMC Article

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