Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children.
Insulin is a commonly used, high-risk medication in the inpatient setting. Incorrect insulin administration can lead to preventable hypoglycemic events, which are a significant morbidity in inpatient diabetes care. The goal of this intervention was to decrease preventable insulin-related hypoglycemic events in an inpatient setting in a tertiary care pediatric hospital.



Methods included the institution of several interventions such as nursing and physician education, electronic medical record order sets, electronic communication note templates, and the development of new care guidelines.



After the institution of multiple interventions, the rate of preventable hypoglycemic events decreased from 1.4 preventable events per 100 insulin days to 0.4 preventable events per 100 insulin days.



Through the use of a multi-interventional approach with oversight of a multidisciplinary insulin safety committee, a sustained decreased rate of severe preventable hypoglycemic events in hospitalized pediatric patients receiving insulin was achieved.
Quality and Patient Safety, Children's Hospital Colorado, Aurora, Colorado; amy.poppy@childrenscolorado.org.
Amy
A
Poppy
Division of Endocrinology.
Claudia
C
Retamal-Munoz
Division of Endocrinology, Barbara Davis Center for Childhood Diabetes, and.
Melanie
M
Cree-Green
Division of Endocrinology, Barbara Davis Center for Childhood Diabetes, and.
Colleen
C
Wood
Division of Endocrinology, Barbara Davis Center for Childhood Diabetes, and.
Shanlee
S
Davis
Division of Endocrinology, Barbara Davis Center for Childhood Diabetes, and Division of Endocrinology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah.
Scott A
SA
Clements
Division of Endocrinology, Barbara Davis Center for Childhood Diabetes, and.
Shideh
S
Majidi
Division of Endocrinology, Barbara Davis Center for Childhood Diabetes, and.
Andrea K
AK
Steck
Division of Endocrinology, Barbara Davis Center for Childhood Diabetes, and.
G Todd
GT
Alonso
Division of Endocrinology, Barbara Davis Center for Childhood Diabetes, and.
Christina
C
Chambers
Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz, Aurora, Colorado; and.
Arleta
A
Rewers
D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006760:Hospitalization; D006776:Hospitals, Pediatric; D006801:Humans; D007003:Hypoglycemia / Q000139:chemically induced / Q000517:prevention & control*; D007004:Hypoglycemic Agents / Q000008:administration & dosage* / Q000009:adverse effects; D007223:Infant; D007328:Insulin / Q000008:administration & dosage* / Q000009:adverse effects; D008297:Male; D017410:Practice Guidelines as Topic; D058996:Quality Improvement; D012189:Retrospective Studies; D012720:Severity of Illness Index; D062606:Tertiary Care Centers; D016896:Treatment Outcome
D007004:Hypoglycemic Agents; D007328:Insulin