Safe Administration of Insulin in the Hospital
Biosynthetic insulin is widely used for controlling blood sugar levels in patients with type 1 diabetes. Insulin is administered subcutaneously in multiple doses with single-use syringes and needles or by using repeated use insulin pens and, in some cases, with the use of an insulin pump.
It is one of the most commonly administered parenteral drugs in the hospital, although its use may also be taught to patients and caregivers. Potential risks in its administration may be severe and life-threatening, and safety measures have to be observed by all who are concerned in its use.
Common Errors in Administering Insulin
Insulin is a parenteral medication that is commonly prescribed and administered in hospitals. Parenteral drugs are those that are given by injection rather than orally, either through the veins, the muscles or through the subcutaneous layer of the skin. As with any other drug, common errors of injecting insulin include:
- Wrong patient being given the drug
- Wrong drug being given to the patient
- Wrong dose of the drug being given to the patient
- Wrong timing of a given dose, including omission of some doses
- Wrong route of administration (i.e., injection was given intravenously instead of subcutaneous)
Other errors in administration which are unique to the characteristics of insulin as a drug are:
- Wrong type of insulin being given
- Failure to properly monitor effects of recent doses of insulin
- Failure to adjust doses of subsequent injections
Safe administration if insulin in the hospital requires avoiding errors in insulin administration stemming from inappropriate prescriptions, inaccurate measurements, poorly written orders which could be misinterpreted or misread, improper handling and storage and many more human errors which may committed by doctors, nurses, pharmacists and other caregivers.
Risks of Insulin Administration
Biosynthetic insulin is used mostly for the proper control of blood sugar levels in type I diabetic patients. These patients do not produce their own hormone so that they are in danger of experiencing hyperglycemia or extreme increases in blood sugar levels. Some type II diabetes patients may also be given insulin when their oral hypoglycemic alone cannot control their blood glucose. With the many possible sources of error in administering insulin, patients are at risk for:
- Hypoglycemia due to overdosing or wrong timing of injections
- Hyperglycemia due to under dosing or skipped doses
- Complications due to either hypoglycemia or hyperglycemia
- Complications due to other errors like tissue damage
Guidelines for Safe and Effective Administration of Insulin in Hospitals
To address the concern for safe and effective use of insulin in hospitals several nurses, doctors and pharmacists formulated guidelines in prescribing, storing, handling and administering the drug. Since this is a multi-disciplinary and concerted effort of different levels of care, everyone is encouraged to be educated on the use of the hypoglycemic agent.
The recommendations for proper use of insulin highlight the following according to levels of involvement:
- Doctors should have adequate knowledge of the patient’s medical history, including other medications being taken.
- They should do proper assessment of all laboratory tests and monitoring of blood glucose levels.
- Prescriptions and orders for insulin should be written legibly, without abbreviations, with accuracy for dosage, timing and type of insulin to be given. Potential drug to drug interactions must be considered.
- Physicians should specify target ranges for glucose levels and instructions for adjustment of dosages when needed. They must also give instructions on emergency situations arising from hypo-or hyperglycemia.
- Pharmacists should be very careful in storing and handling insulin products. Orders for insulin preparation should be reviewed and recorded.
- Distribution, preparation and dispensing insulin products are their main concern, and these should be done accurately according to hospital protocols.
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Guidelines for Safe and Effective Administration of Insulin in Hospitals (part 2)
- Nurses have the delicate responsibility of administering insulin to the patients. For this reason, their knowledge and skills are of utmost importance. They must be able to judge if insulin should be given after monitoring blood sugar levels.
- Safety precautions should be observed with regards to reading, transcribing and carrying out orders from the physician. They must also follow the prescribed hospital protocols in storing, handling and preparing insulin for use.
- Nurses should pay particular attention to avoid the common errors of drug administration by:
- Ensuring the identity of the patient
- Double checking dosages, type of insulin and timing of administration of the drug, taking note of dose adjustments.
- Carefully monitoring the blood sugar levels of the patient before and after the injections, and checking for reactions.
- Rotating the sites of injection to prevent tissue changes (hypertrophy)
- Ensuring proper technique of injection, with care as to asepsis and accuracy – proper technique of subcutaneous injection is done by inserting the needle at full length at a 45 to 90 degree angle
- Taking care not to massage the site of injection
- Proper documentation after administration of the drug
Some institutions allow patients who are capable of insulin self-administration and self-monitoring to do the injections themselves. For these patients insulin pumps, insulin pens or syringes may be used. Doctors and nurses should make sure these patients are properly trained and supervised during the procedure.
Insulin should not be stored by the bedside, nor the patient be allowed to keep and use them without supervision. Whenever the patient self-administers insulin and monitors his own blood sugar level, the nurse must be present to witness and document the event.
Meeting Blood Glucose Targets
For patients who are not in critical condition the blood glucose target range is between 90-130 mg/dl or an average of 110 mg/dl. A maximum of 180 mg/dl is tolerated.
Patients in critical care units need a tighter control for management of blood sugar, with the ideal of 110 mg/dl. Patients who undergo surgery, have severe infection, taking steroids and being fed through tubes usually need higher doses of insulin. Adjustments to these requirements must be considered by the doctors and nurses attending to the patients with proper monitoring of responses.
Hospitals usually use sliding scale insulin dosage algorhythms to correct or adjust doses of insulin and prevent hypoglycemia or hyperglycemia. Doctors and nurses must be well trained in assessing the need to use these algorhythms.
Monitoring blood glucose levels at least 5 times a day (before meals, at bedtime and at 2 am) in patients who are eating may be done to prevent hyperglycemia. For patients who are not allowed to eat monitoring may be done every 4 to six hours. Hypoglycemia may occur if the patient is vomiting or not eating, so the need for intravenous glucose must be assessed.
Insulin is an essential drug in the effective management of diabetes and is being used worldwide in many hospitals and health institutions. Insulin administration can be done safely and effectively through the concerted efforts of the physicians, nurses, pharmacist and the patients themselves. Learning the basics of insulin use and following hospital protocols and principles for avoiding common drug errors are essential in keeping the patient safe from hypoglycemia, hyperglycemia and other complications.