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Clarity in Insulin Coverage Orders

From our partners at the Institute for Safe Medication Practices (ISMP): 

The Diabetes Control and Complications Trial, a prospective, randomized controlled trial of intensive versus standard glycemic control involving inpatients with relatively recently diagnosed type 1 diabetes, showed that improved glycemic control is associated with significantly decreased rates of microvascular (retinopathy and nephropathy) as well as neuropathic complications. This led to the recommendation that type 1 diabetes be treated by using multiple insulin injections (three to four injections per day of basal and prandial insulin) as well as by matching the dose of prandial insulin to carbohydrate intake, pre-meal blood glucose, and anticipated activity.

However, the use of multiple-dose injections of insulin throughout the day has added complexity to controlling a patient’s blood glucose. For example, correction doses, sometimes referred to as “coverage” or erroneously as “sliding scales,” are used to adjust glucose levels around mealtimes. Organizations often have multiple algorithms for corrections doses, such that a facility may have “low dose,” “medium dose,” and “high dose” algorithms that require the nursing staff to obtain and document each patient’s blood glucose reading, determine the patient’s ordered algorithm, and then select the proper dose based on the blood glucose reading.

The predominant theme mentioned in reports of wrong-dose events involves the dosing of insulin based on a range of blood glucose values with a corresponding coverage dose, determined by a patient’s blood glucose reading. Of the wrong-dose errors submitted to the Authority (n = 712), 26% (n = 185) mention coverage or sliding scales. (Many events reported to the Authority used the phrase “sliding scale” in the narratives to denote the method used to determine the dose of insulin to administer to patients. While this term may be used in place of “correction dose” or “coverage,” it should be noted that sliding-scale insulin regimens used alone are ineffective and potentially harmful. When using subcutaneous insulin injection therapy, scheduled or standing insulin regimens should be the standard of care.) As mentioned previously, this recommended method of maintaining tight control of a patient’s blood sugar, regardless if the patient is diabetic or not, adds complexity to the medication-use process for all healthcare practitioners.

One problem often seen with coverage orders is the clarity of handwritten orders from physicians, a particular problem when an organization does not have a standardized protocol or order form to order insulin, including the type of coverage (e.g., low, high). Adding to the complexity of these orders are the multiple values often used for multiple ranges of blood sugars. Problems have also occurred when shortcuts are taken when writing these types of orders for insulin. For example, orders have been written stating doses of insulin as “6+1” or “6+2” instead of writing out “7” or “8” (see Figure 1).

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Diabetes in Control would like to acknowledge the Institute for Safe Medication Practices’ outstanding work in medication safety, including the above excerpt.

Report Medication Errors to ISMP:

Diabetes in Control is partnered with the Institute for Safe Medication Practices (ISMP) to help ensure errors and near-miss events get reported and shared with millions of health care practitioners. The ISMP is a Patient Safety Organization obligated by law to maintain the anonymity of anyone involved, as well as omitting or changing contextual details for that purpose. Help save lives and protect patients and colleagues by confidentially reporting errors to the ISMP.

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