Sunnybrook Health Sciences Centre, Toronto, Canada.
Can J Diabetes. 2014 Apr;38(2):94-100. doi: 10.1016/j.jcjd.2014.01.002.
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.
确保在医院中安全、适当地使用抗高血糖药物是一项挑战。这需要遵守非胰岛素药物使用的禁忌证和注意事项，尽量减少低血糖和严重高血糖的发生，降低用药错误（包括不当处方）的风险。胰岛素是一种高危药物，如果不当处方或给药错误，会增加患者伤害的风险。要降低用药错误的风险，需要密切关注用药过程各个阶段的许多详细步骤。低血糖通常是由于未能根据营养摄入减少来调整抗高血糖治疗引起的。治疗需要更紧密地与患者的营养状况相关联，并且应该授权护理人员迅速启动低血糖逆转。高血糖通常是由于依赖胰岛素剂量调整作为控制血糖的唯一方法或未能通过增加胰岛素剂量来优化治疗引起的。胰岛素的处方不规范可能是由于处方者缺乏知识和专业知识，或者担心引起低血糖。改善血糖控制的策略包括对护理人员进行胰岛素安全和适当使用的教育，制定胰岛素使用的标准化方案（即医嘱集），并在护理点提供临床决策支持工具，以指导处方者。考虑到医院面临的挑战和障碍，建议成立一个多学科委员会，旨在指导医院内糖尿病护理质量改进工作。
