ISMP Canada, with support from the Ontario Ministry of Health and Long-Term Care, undertook a knowledge translation project on insulin use interventions and safeguards based on learnings from the Ontario Critical Incident Learning Program. As part of this project, ISMP Canada convened an expert panel to select 2 key insulin-use interventions and then asked expert working groups to develop specific guidelines and templates to support the selected key interventions.

INTERVENTIONS

1. Develop and implement a diabetes management record:

• Create a record where all relevant aspects of a patient's glycemic management can be documented to facilitate decision-making with regard to insulin therapy.
• Information to be documented in this record includes results of blood glucose testing, details of every insulin dose administered, nutritional status, occurrence of hypoglycemic episodes, and other factors that may affect blood glucose.

2. Use standard order sets for subcutaneous insulin therapy:

• Develop organization-wide, evidence-based standards and standardized terminology for ordering subcutaneous insulin.
• Develop recommendations for prescribing and monitoring subcutaneous insulin.
• Discourage the use of sliding-scale insulin alone.
• Promote the use of scheduled basal and bolus insulin doses, as well as appropriate correction doses.

INTERVENTION TOOLS*

Report to the Ontario Ministry of Health and Long-Term Care: Knowledge Translation of Insulin Use Interventions / Safeguards - PDF

Diabetes Management Record - Subcutaneous Insulin - (Template) PDF

• Subcutaneous Insulin Order Set - Eating - (Template) PDF
• Subcutaneous Insulin Order Set - NPO - (Template) PDF
• Subcutaneous Insulin Order Set - Enteral / Parenteral Feeds - (Template) PDF

The tools developed for this project include a report on the knowledge translation of insulin-use interventions, a template for a diabetes management record, and guidelines for developing order sets for subcutaneous insulin, as well as templates for such order sets. The guidelines and templates that were developed can be customized for use in community or academic hospitals and can be used with both paper-based and electronic systems and processes. These intervention tools and other resources are available for hospitals to use and adapt to meet their own requirements.

Insulin is a high-alert medication that continues to be one of the top drugs involved in incidents associated with harm or death that are voluntarily reported to ISMP Canada. Efforts to reduce the potential for harm with this drug have resulted in numerous recommendations on best practices for improving the safety of insulin use in hospitals. These strategies touch on all aspects of insulin use throughout the medication-use process. Although many of these interventions have been adopted by hospitals, harmful incidents involving insulin continue to occur.

The knowledge translation project was accomplished through multiple steps:

PHASE ONE

• A literature search was performed to identify published recommendations for the safe use of insulin.
• A survey was developed and disseminated to capture current insulin-use safety strategies and potential deficiencies in Ontario hospitals.
• The safeguards and strategies identified through both the literature search and the survey were reviewed, and interventions were retained for further consideration only if they were deemed to be highly effective and measurable.
• These interventions were then categorized by the stage of the medication-use process where they would be applicable and presented to an expert panel.
• The expert panel assessed each intervention according to the hierarchy of effectiveness, feasibility of implementation, and measurability of impact and selected 2 interventions.

PHASE TWO

• Working groups of nurses, physicians, and pharmacists were established to assist in development of guidelines and templates for the 2 selected interventions.
• The working groups reviewed existing diabetes management records and order sets for subcutaneous insulin already in use in selected hospitals in Ontario, along with resources from Australia and the United States.
• The guidelines and templates were subjected to a series of revisions before consensus was reached on their key components, their perceived ability to facilitate appropriate treatment decisions, and a user-friendly layout.

Good glycemic control through the use of insulin has important health benefits for individuals with diabetes, but strategies are needed to reduce the potential for preventable harm associated with this drug. Individual practitioners and administrators in Ontario healthcare facilities are encouraged to review insulin management processes within their own organizations and to use the resources provided by ISMP Canada to support safe and effective care.

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PHASE ONE - Expert Panel

Margaret Colquhoun, RPh, BScPhm, FCSHP
Project Leader
Institute for Safe Medication Practices Canada

William Cornish, RPh, BScPhm, ACPR
Supervisor, Drug Information
Department of Pharmacy
Sunnybrook Health Sciences Centre

Nancy Coulis, RN
Patient Care Manager
Mackenzie Health

Julia Lowe, MBChB, M.Med.Sci.
Associate Professor of Medicine,
University of Toronto
Division of Endocrinology
Sunnybrook Health Sciences Centre

Jessica Ma, RPh, BscPhm, ACPR
Project Leader
Institute for Safe Medication Practices Canada

Norma Lynn Pearson, RPh, BScPhm
Pharmacy Operations Manager
The Ottawa Hospital

Kimindra Tiwana, RPh, BScPhm, ACPR
Project Leader
Institute for Safe Medication Practices Canada

Kris Wichman, RPh, BScPhm, ACPR
Project Leader
Institute for Safe Medication Practices Canada

David U, MScPhm
President and CEO
Institute for Safe Medication Practices Canada

PHASE TWO - Expert Working Group Participants

Jeff Chan, RPh, PharmD
Manager, Pharmacy
Thunder Bay Regional Health Sciences Centre
Assistant Professor
Northern Ontario School of Medicine

William Cornish, RPh, BScPhm, ACPR
Supervisor, Drug Information
Department of Pharmacy
Sunnybrook Health Sciences Centre

Robyn Houlden, MD, FRCPC
Professor, Division of Endocrinology, Queen's University
Kingston General Hospital

Sara Kynicos, M.Pharm, R.Ph
Pharmacy Operations Manager
Toronto Western Hospital and Toronto Rehab Institute

Hoping Li, RPh BScPhm
Staff Pharmacist
Grey Bruce Health Network

Allan Mills, RPh, BscPhm, ACPR, Pharm D
Director of Pharmacy
Trillium Health Partners

Sarah Moore, RN (EC), MN
Diabetes Advanced Practice Nurse/ Nurse Practitioner
Kingston General Hospital

Sunil Patel, BScPhm, HBSc, ACPR
Clinical Pharmacy Manager
William Osler Health System

Gillian Revie, RN, BA, BScN, CNCC(C)
Quality, Safety and Risk Consultant
Trillium Health Partners

Kimindra Tiwana, RPh, BScPhm, ACPR
Project Leader
Institute for Safe Medication Practices Canada

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The order sets displayed were prepared by individual named hospitals solely for internal use. These hospitals have authorized ISMP Canada to post this material as examples only. These materials are shared with the understanding that the named hospitals accept no responsibility for its use by any person who is not a staff member of, patient at, or otherwise associated with their facility.

Grey Bruce Health Network^*:

• Subcutaneous Insulin Order Set - PDF

Kingston General Hospital^*:

• Diabetes Management - Subcutaneous Insulin Therapy NPO Order Set (Adult) - PDF
• Diabetes Management - Subcutaneous Insulin Therapy Patient Eating Order Set (Adult) - PDF
• Diabetes Management - Tube Feeding/Parenteral Nutrition Order Set (Adult) - PDF

Sunnybrook Health Sciences Centre:

• Standard Subcutaneous Insulin Orders for Non-pregnant Patients - PDF

Trillium Health Partners:

• Physician's Orders - Insulin Subcutaneous Therapy (Adult) - PDF

William Osler Health System:

• Insulin Orders for Patients with Type 2 Diabetes Order Set - PDF

External Links

• Canadian Diabetes Association Clinical Practice Guidelines 2013
• Australia National Subcutaneous Insulin Form - Pilot Project
• Cobaugh DJ, Maynard G, Cooper L et al. Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel. Am J Health-Syst Pharm. 2013;70:e18-27.
• Society of Hospital Medicine Glycemic Control Resource Room
• Healthcare Human Factors Group - University Health Network. Order sets in healthcare: an evidence-based analysis 2009
• Institute for Safe Medication Practice Guidelines for Standard Order Sets 2010 - PDF

^* these order sets were made in partnership with PatientOrderSets.com

What is the Safe Use of Insulin Pens e-Learning module?

The insulin pen e-Learning module is meant to provide a general introduction to the Safe Use of Insulin Pens for healthcare providers. It is not meant to replace hands-on training. It was created by ISMP Canada with support from the Ontario Ministry of Health and Long-Term Care for hospitals in Ontario.

Who is it meant for?

This module is meant to inform nurses, pharmacists and other healthcare professionals involved with delivering insulin.

How does it benefit the health-care providers?

It helps them to:

• Understand the risks associated with insulin pen use in hospital settings.
• Understand how to use insulin pens safely in hospital settings.
• Learn best practice techniques associated with insulin pens.
• Become familiar with some advantages and disadvantages of insulin pens.

Where can I get access to the Safe Use of Insulin Pens e-Learning module?

Please see our eLearning site to access the module.

For institutional access, please send an email to education@ismp-canada.org.

In the winter of 2014, ISMP Canada, in collaboration with the Canadian Society of Hospital Pharmacists Ontario Branch, hosted a roundtable discussion on the 'Safe Delivery of Insulin'

Safe Delivery of Insulin: Summary Report and Recommendations

The goals of the roundtable were to provide guidance to practitioners in hospitals on:

• Identifying medication safety considerations for insulin pens and multi-dose vials and syringes;
• Assessing infection control risks associated with insulin pens and multi-dose vials and syringes; and
• Proposing recommended strategies to promote safe administration of insulin in acute care settings

Participants of the roundtable included:

References:

ALERT: Use of one insulin pen for multiple patients is a high-risk practice. ISMP Canada. 2013;13(4):1-4
(http://www.ismp-canada.org/download/safetyBulletins/2013/ISMPCSB2013-04_ALERT_InsulinPenHighRiskPractice.pdf)

Considering insulin pens for routine hospital use? Consider this. ISMP Med Saf Alert. 2008 [cited 2014 Apr 24];13(9):1-3. Available from: https://www.ismp.org/newsletters/acutecare/articles/20080508.asp

Cobaugh DJ, Maynard G, Cooper L, Kienle PC, Vigersky R, Childers D, Weber R, Carson SL, Mabrey ME, Roderman N, Blum F, Burkholder R, Dortch M, Grunberger G, Hays D, Henderson R, Ketz J, Lemke T, Varma SK, Cohen M. Enhancing insulin-use safety in hospitals: Practical recommendations from an ASHP Foundation expert consensus panel. Am J Health Syst Pharm. 2013 Aug 15;70(16):1404-13. (http://www.ashpmedia.org/AJHP/Enhancing-insulin-use-safety-in-hospitals.pdf)

Insulin pen safety - one insulin pen, one person. Atlanta (GA): Centers for Disease Control and Prevention and Safe Injection Practices Coalition; [cited 2013 Apr 11]. Available from: http://www.oneandonlycampaign.org/content/insulin-pen-safety