Hypoglyemi Agent Adverse Drug Event Gap Analysis Component of Mediation Management Assessment Speifi Ation(s) Speifi Ation plan(s) inluding persons responsible and timeline to omplete. Prevention and Mitigation Strategies 1) Systems and proesses for blood gluose monitoring praties The faility has established blood gluose targets for: 1a) Critially ill patients. 1b) Non-ritially ill patients. 1) Pregnant patients with gestational diabetes mellitus (GDM) or pre-existing diabetes. 1d) Neonate/pediatri patients. The faility has established blood gluose monitoring guidelines, (inluding point of are [POC] testing for more rapid rest results), for: 1e) Patients with diabetes. 1f) Patients with hospital-aquired hyperglyemia (without diabetes). 1g) Pregnant women who are eating and have gestational diabetes mellitus or pre-existing diabetes. 1h) Neonate/pediatri patients. 2) Management prourement, storage, preparation, and dispensing praties The faility has proesses in plae to eliminate errors in presribing, dispensing, and administration whih inludes: 2a) Pharmay prepares individual patient-sheduled doses of intermediate or long-ating insulins unless provided as individual patient insulin devies (e.g., pens). 2b) Floor stoks of insulins is minimized or eliminated. 2) Insulin is not available from automated dispensing abinet (ADC) without review of insulin orders by a pharmaist. 2d) If override is allowed for emergent situation, an independent double-hek by two professionals ours upon removal from ADC. 2e) All insulin infusions, onentrated insulin (U-500), and diluted insulins individual patient-speifi doses are prepared in the pharmay. Page 1 Hypoglyemi Agent Adverse Drug Event Gap Analysis Component of the Mediation Management Assessment 2012 Minnesota Hospital Assoiation. Used with permission.
Speifi Ation(s) Speifi Ation plan(s) inluding persons responsible and timeline to omplete. 2f) The number of standard onentrations used for insulin infusions is limited to one. 2g) An independent double hek is instituted prior to dispensing non-standard onentrations of sub-utaneous insulin (eg. U500 and U10 insulin) and preparations of IV infusions. 3) Management ordering praties 3a) The faility has a proess in plae to streamline formulary to single brand soure for eah insulin type with approved substitutions. 4) Management administration and monitoring The faility has proesses in plae to ensure: 4a) All insulin infusions are administered using an IV pump with free-flow protetion and smart-pump tehnology with appropriately defined max./min. infusion rates, alerts, and override riteria. 4b) An independent double-hek is required before administering all IV insulin. 4) An independent double-hek is required before administering non-standard insulin onentrations (e.g., U-500). 4d) Tuberulin syringes are removed from floor stok so they annot erroneously be used for insulin. Standard praties are established for subutaneous insulin dosing for the following situations: 4e) Non-standard insulin onentrations (e.g., U-500 insulin) 4f) Corretion sale(s) 4g) Basal prandial dosing (arbohydrate/non-arbohydrate) 4h) Pre-operative or pre-proedural protool 4i) Converting from oral agents to insulin Standard insulin infusion protools exist and are in use for: 4j) ICU. 4k) Non-ICU. 4l) Diabeti ketoaidosis (DKA). 4m) Hyperosmolar hyperglyemi state (HHS). 4n) Pregnany. Page 2 Hypoglyemi Agent Adverse Drug Event Gap Analysis Component of the Mediation Management Assessment 2012 Minnesota Hospital Assoiation. Used with permission.
Speifi Ation(s) Speifi Ation plan(s) inluding persons responsible and timeline to omplete. The faility has a poliy in plae for patients with self-managed subutaneous insulin pumps whih speifies: 4o) Poliy speifies and pratie ensures that patient must be ognitively ompetent and safe to self-administer. Standard praties are established for oral and injetable noninsulin anti-hyperglyemi agents, whih inlude: 4p) Use of oral and injetable non-insulin anti-hyperglyemi agents (gluose-like peptide [GLP]1 analogs and pramlintide) is restrited in aute are settings. (Insulin is the preferred agent.) 4q) Sulfonylurea agents are avoided with NPO (nothing by mouth) patients and patients with inonsistent nutritional intake. 4r) Thiazolidinedione use is avoided in patients with ongestive heart failure (CHF). 4s) Metformin use is avoided in patients who are ritially ill, have a reatinine greater than 1.4 mg/dl females or 1.5 mg/dl males, have reeived IV ontrast or have abnormal reatinine learane. 4t) There is a proess in plae to ensure that protools/poliies order sets are implemented and being used onsistently. 5) Implement appropriate mitigation strategies The faility has a proess in plae for follow up after initial hypoglyemi reation ours whih inludes: 5a) The adjustment of insulin dose. 5b) The implementation of standard blood gluose (BG) monitoring after treatment of hypoglyemia with gluagon or D50 (e.g., 0200 gluose hek, gluose q 1 hr X 3). 5) A plan for ongoing monitoring and dose adjusting to prevent hypoglyemia reourrene. Assessment and Detetion Strategies 6) Systems and proesses to aid in assessment and detetion 6a) The faility s insulin administration reord, gluose monitoring results, and arbohydrate intake are effetively displayed to allow aregivers to aurately and effiiently assess data. The faility implements real-time rules/alerts to flag low blood gluose triggers and hanges in patient ondition predisposing patient to hypoglyemia, whih inlude: 6b) Change in nutrition and/or fluid status admission, aute illness, NPO for surgery, start/stop parenteral nutrition (PN)/ enteral nutrition (EN), inonsistent nutrition in hospital. Page 3 Hypoglyemi Agent Adverse Drug Event Gap Analysis Component of the Mediation Management Assessment 2012 Minnesota Hospital Assoiation. Used with permission.
Speifi Ation(s) Speifi Ation plan(s) inluding persons responsible and timeline to omplete. 6) Addition or disontinuation of mediation(s) that affet blood gluose. 6d) Disease state aute renal failure (ARF), aute hepati failure, severe sepsis/shok. 6e) Transitions in are/hand-offs. 7) Management assessment of nutrition and fluid status 7a) The faility has a proess in plae to oordinate blood gluose heks, meals, and insulin administration times. The faility has a proess in plae to monitor for mismath between nutritional intake in patients with fixed prandial dosing: 7b) Upon admission. 7) For patients with inonsistent nutritional intake or failure to eat after prandial insulin dose has been given. 7d) At transitions in are. The faility has a proess in plae that requires new insulin orders and BG monitoring for patients on insulin with: 7e) Change in nutrition status (e.g., new NPO status, transition from PN to EN, transition from ontinuous to yli PN or EN). 7f) Disontinuation of total PN (TPN)/dextrose ontaining IV fluid or EN. 8) Management with other mediations affeting blood gluose ontrol The faility has a proess in plae for management of insulin used with other mediations that may affet blood gluose ontrol, whih inludes: 8a) Assessing appropriateness of ontinuation of injetable non-insulin, anti hyperglyemi agents, and oral agents upon admission. 8b) Ensuring that appropriate warnings appear in information systems (e.g., omputerized physiian order entry [CPOE], MAR, pharmay) when mediations that signifiantly alter BG levels or insulin regimen requirements are started or stopped or the dose is inreased (e.g., Cortiosteroid taper, Quinolones Otreotide, antipsyhoti agents, ontinuous renal replaement therapy [CRRT], vasopressors, immunosupressants). 9) Management with disease states affeting blood gluose ontrol The faility has proesses in plae for management of insulin use in the following disease states: 9a) Renal dysfuntion: Use of an algorithm to determine need for redution of weight-based insulin dosing. 9b) Liver dysfuntion: Use of an algorithm to determine need for redution of weight-based insulin dosing. Page 4 Hypoglyemi Agent Adverse Drug Event Gap Analysis Component of the Mediation Management Assessment 2012 Minnesota Hospital Assoiation. Used with permission.
Speifi Ation(s) Speifi Ation plan(s) inluding persons responsible and timeline to omplete. 9) Malnutrition/low body weight: Use of an algorithm to determine need for redution of weight-based insulin dosing. 9d) Type 1 diabetes: Should have dextrose added to IV fluids if no alori intake. 9e) Hyperkalemia: Insulin should be used to treat hyperkalemia only via the use of a protool that inludes speifi blood sugar monitoring. 10) Management hand-offs and transitions A standard hand-off/transition ommuniation proess is in plae for all patients reeiving insulin whih inludes the following information, at minimum: 10a) Communiation of last blood gluose hek. 10b) Date and time of last insulin dose given. Therapeuti Strategies 11) Systems and proesses for insulin therapeuti strategy praties 11a) The faility has a proess in plae to enourage omanagement of insulin with patients who are apable and willing (e.g., enourage patients to question doses and timing of insulin administration). The faility has insulin management praties in plae, whih inlude: 11b) Mathing insulin prandial dosing to the amount of arbohydrate onsumed. 11) Cheking blood gluose within 30 minutes before meal. 11d) Administering rapid-ating prandial insulin within 30 minutes post first bite. 11e) Avoiding dose staking (e.g., orretive insulin should not be given more frequently than every 4 hours for rapid-ating insulin or every 6 hours for regular insulin). 12) Management hyperglyemia management praties The faility has a proess in plae for management of hyperglyemi patients using basal/bolus insulin, whih inludes: 12a) Intermittent sliding-sale insulin regimens are onsistently used with a basal insulin. 12b) Rapid-ating insulin is the standard hoie of therapy for prandial insulin. 12) Prandial and orretion-sale insulin should be the same type of insulin and given in one injetion when possible. Page 5 Hypoglyemi Agent Adverse Drug Event Gap Analysis Component of the Mediation Management Assessment 2012 Minnesota Hospital Assoiation. Used with permission.
Speifi Ation(s) Speifi Ation plan(s) inluding persons responsible and timeline to omplete. The faility has a proess in plae for management of hyperglyemi patients using mixed insulin whih inludes: 12d) Dosing ours only before breakfast and before dinner; not at bedtime. 12e) Patients are monitored for noturnal hypoglyemia. 12f) Change to basal/prandial if patient beomes NPO or exhibits inonsistent nutritional intake (e.g., poor appetite). 13) Management hypoglyemia management praties The faility has an established standard order set or protool, approved by medial staff ommittee, in plae for management of hypoglyemi patients whih inludes: 13a) A standard method for management of hypoglyemia, inluding triggers to administer gluose, (e.g., blood gluose value below threshold, signs and symptoms of hypoglyemia) is readily available to aregivers. 13b) Allows nurses to administer hypoglyemia resue agents without prior physiian order. 13) Hypoglyemia resue agents (dextrose, gluagon) are readily aessible throughout the faility where are is provided. Critial Thinking and Knowledge Strategies 14) Implement appropriate ritial thinking and knowledge strategies The faility has a proess in plae whih evaluates staff ompetenies related to hypoglyemi agent use inluding: 14a) Hypoglyemia is always onsidered when a patient reeiving insulin has an altered level of onsiousness for no apparent reason. 14b) Hypoglyemia should not be ruled out as a ause of onfusion or altered behavior based on a apillary BG result; a venous lab result should also be obtained. The faility provides interdisiplinary eduation on hypoglyemi agent therapy, whih inludes: 14) Initial training for new hires and existing staff, inluding protools and guidelines. 14d) Post test inorporating a ase-study approah to demonstrate profiieny; overs topis suh as: frequeny of gluose heks; non-standard insulin onentrations (e.g., U-500 insulin); orretion insulin sale(s); basal insulin dosing; prandial insulin dosing (arbohydrate/non-arbohydrate); pre-operative or pre-proedural protools; onverting from oral agents to insulin. 14e) Plan for targeting gaps in knowledge. 14f) Hypoglyemi agent eduation is provided to diret are staff members when new relevant information is available. Page 6 Hypoglyemi Agent Adverse Drug Event Gap Analysis Component of the Mediation Management Assessment 2012 Minnesota Hospital Assoiation. Used with permission.
Speifi Ation(s) 15) Provide patient and family eduation Patient Eduation The faility has a proess in plae to eduate patients and families using teah-bak method on diabetes survival skills to ensure safe therapy inluding: 15a) Nutritional management. Speifi Ation plan(s) inluding persons responsible and timeline to omplete. 15b) Self-blood gluose monitoring. 15) Mediation management. 15d) Hyperglyemia and hypoglyemia reognition. 15e) Treatment and prevention. 15f) Exerise. 15g) Sik day guidelines. 15h) Resoures. 15i) Post-disharge follow-up appointment. This Material was adapted by Health Servies Advisory Group, the Mediare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under ontrat with the Centers for Mediare & Mediaid Servies (CMS), an ageny of the U.S. Department of Health and Human Servies, from material originally prepared by Minnesota Hospital Assoiation. 2012/2013 Minnesota Hospital Assoiation. Used with permission. The ontents presented do not neessarily reflet CMS poliy. Publiation No. AZ-11SOW-C.3-07062015-03 Page 7 Hypoglyemi Agent Adverse Drug Event Gap Analysis Component of the Mediation Management Assessment 2012 Minnesota Hospital Assoiation. Used with permission.