The Institute for Safe Medication Practices (ISMP) recently released its biennial Targeted Medication Safety Best Practices for Hospitals which serve to identify, inspire and mobilize widespread adoption of consensus-based best practices in hospitals to address recurring problems that continue to cause fatal and harmful errors. The ISMP Best Practices are high-leverage error-reduction strategies rooted in scientific research and expert analysis of medication errors and their causes. While these guidelines might be challenging for some organizations to achieve, ISMP believes they are practical and feasible, and that their implementation can vastly improve medication safety and reduce the risk of significant patient harm.
ISMP introduced three new best practices in the 2022-23 Targeted Medication Safety Best Practices for Hospitals list, including one that focuses specifically on high-alert medications. I sat down with Stephanie Mason, PharmD, CDCES, Diabetes Clinical Pharmacist at Glytec, to discuss what these new best practices mean for how hospitals address insulin and glycemic management in the hospital.
Day: Can you give us a brief overview of the new best practices and how they impact insulin management in the hospital?
Mason: ISMP is a leader in best practice recommendations around the use of medications in the hospital. Its initial Targeted Medication Safety Best Practices for Hospital list contained six best practices and the list has now grown to include 19 sets of guidelines.
The three best practices introduced this year focus on safeguarding against errors with oxytocin use, expanding the use of barcode verification beyond inpatient care areas and layering numerous strategies throughout the medication-use process to improve safety with high-alert medications. Insulin is of course a high-alert medication and is impacted by Best Practice 19 and the high-alert medication we’ll be talking about today.
The guidance for hospitals recommends that institutions implement robust processes to ensure the safe use of insulin over the entire medication-use process. This includes the prescribing, transcribing and documenting, dispensing, administering and monitoring of insulin. Health systems should also conduct regular risk assessments of the processes and practices they have in place to support the safe use of insulin.
ISMP also recommends institutions focus on mid- and high-leverage risk-reduction strategies such as EHR tools, technology, and clinical decision support software to prevent errors and utilize process metrics and data to drive improvement.
Day: What does this mean for inpatient glycemic management, both currently and moving forward?
Mason: This is another clear indication that glycemic management can no longer continue to sit on the back burner. US Centers for Medicare & Medicaid Services (CMS) released its quality measures surrounding severe hypo- and hyperglycemia, and now ISMP is calling for a stronger and safer medication-use process for all high-alert medications which includes insulin.
The use of insulin in the hospital is high whether that’s via an IV infusion or subcutaneous injection. And we expect this because the number of hospitalized patients with diabetes or hyperglycemia in the hospital is high. So it’s no longer a matter of if hospital dollars will be directly tied to inpatient glycemic management, but rather when.
The reality is though, suboptimal glycemic management is already costing hospitals millions in the form of increased length of stay, post-op infections and readmissions. But there’s this dirty little secret in healthcare that no one likes to talk about. And it’s the fact that too many health systems are okay with providing care to hospitalized patients with diabetes or hyperglycemia that falls short of best practices.
This complacency and inaction around inpatient glycemic management starts at the top with hospital executives, and one of the simplest examples we see are facilities that still use sliding-scale insulin as the singular approach to managing hyperglycemia in the hospital. There is ample evidence showing that sliding scale can be harmful to patients and national guidelines haven’t supported its use for several years.
Day: How can pharmacists support the implementation and achievement of these best practices, particularly around insulin and other high-alert medications?
Mason: Pharmacists are well-positioned to leverage their knowledge and medication expertise to drive positive change in the adoption of best practices, especially when it relates to insulin and high-alert medication use processes in the hospital. Pharmacists can do this by critically evaluating every step in the medication-use process. This should include identifying where errors are occurring or most likely to occur and exploring solutions that can be put in place to minimize the risk of future errors.
These solutions should feature a combination of low-leverage risk reduction strategies with mid- and high-leverage risk reduction strategies. These may include educating staff on the basics of diabetes and insulin management, building alerts or automating steps in the process using the EHR, and deploying a clinical decision support tool to standardize practice and align with best practice.
At the end of the day, each institution is faced with a decision to either do something or do nothing. There are challenges and consequences with both options, but it’s clear which direction the healthcare landscape is moving in.