降低住院儿童中与胰岛素相关的可预防严重低血糖事件的发生率
Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children.
作者信息
Poppy Amy, Retamal-Munoz Claudia, Cree-Green Melanie, Wood Colleen, Davis Shanlee, Clements Scott A, Majidi Shideh, Steck Andrea K, Alonso G Todd, Chambers Christina, Rewers Arleta
机构信息
Quality and Patient Safety, Children's Hospital Colorado, Aurora, Colorado;
Division of Endocrinology.
出版信息
Pediatrics. 2016 Jul;138(1). doi: 10.1542/peds.2015-1404. Epub 2016 Jun 17.
OBJECTIVE
Insulin is a commonly used, high-risk medication in the inpatient setting. Incorrect insulin administration can lead to preventable hypoglycemic events, which are a significant morbidity in inpatient diabetes care. The goal of this intervention was to decrease preventable insulin-related hypoglycemic events in an inpatient setting in a tertiary care pediatric hospital.
METHODS
Methods included the institution of several interventions such as nursing and physician education, electronic medical record order sets, electronic communication note templates, and the development of new care guidelines.
RESULTS
After the institution of multiple interventions, the rate of preventable hypoglycemic events decreased from 1.4 preventable events per 100 insulin days to 0.4 preventable events per 100 insulin days.
CONCLUSIONS
Through the use of a multi-interventional approach with oversight of a multidisciplinary insulin safety committee, a sustained decreased rate of severe preventable hypoglycemic events in hospitalized pediatric patients receiving insulin was achieved.
目的
胰岛素是住院环境中常用的高风险药物。胰岛素给药不当可导致可预防的低血糖事件，这在住院糖尿病护理中是一种显著的发病情况。本次干预的目标是在一家三级护理儿科医院的住院环境中减少可预防的胰岛素相关低血糖事件。
方法
方法包括开展多项干预措施，如对护士和医生进行教育、使用电子病历医嘱集、电子通信记录模板以及制定新的护理指南。
结果
在采取多项干预措施后，可预防低血糖事件的发生率从每100胰岛素日1.4起可预防事件降至每100胰岛素日0.4起可预防事件。
结论
通过采用多干预方法并由多学科胰岛素安全委员会进行监督，在接受胰岛素治疗的住院儿科患者中，严重可预防低血糖事件的发生率持续下降。
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