Safe and appropriate use of insulin and other antihyperglycemic agents in hospital.

Ensuring safe and appropriate use of antihyperglycemic agents in hospital is a challenge. It requires that the contraindications and precautions to the use of non-insulin agents be observed, the incidence of hypoglycemia and severe hyperglycemia be minimized, and the risk of medication errors (including inappropriate prescribing) be reduced. Insulin is a high-alert medication with an increased risk for causing patient harm when prescribed inappropriately or administered in error. Reduction in the risk for medication error requires close attention to the many detailed steps in the various phases of the medication-use process. Hypoglycemia is often caused by failure to adjust antihyperglycemic therapy in response to a reduction in nutritional intake. Treatment needs to be more closely linked to patients' nutritional status, and nursing staff should be empowered to initiate prompt reversal of hypoglycemia. Hyperglycemia commonly results from reliance on sliding-scale insulin as the sole method of controlling blood glucose or failure to optimize treatment by increasing the dose of insulin. Suboptimal prescribing of insulin may be due to a lack of knowledge and expertise on the part of the prescriber or fear of causing hypoglycemia. Strategies for improvement of glycemic control include education of care providers on the safe and appropriate use of insulin, establishment of standardized protocols (i.e. order sets) for insulin use and provision of clinical decision aids at the point of care to guide prescribers. Considering the challenges and obstacles faced by hospitals, establishment of a multidisciplinary committee is recommended for the purpose of directing efforts at quality improvement of diabetes care within the hospital.