The Patient Safety Movement Pledge to Improve Prevention of Severe Hypoglycemia: Part 3

In part 2 of this series dedicated to the Patient Safety Movement Pledge, we educated our readers on the performance gap and explained that hospitals and healthcare systems will have to take action in specific leadership, practice, and technology plans in order to predict and prevent severe hypoglycemia episodes. Below are the suggested plans.

Leadership Plan

• Must include the fundamentals of change outlined in the National Quality Forum Safe Practices
• Hospital governance must understand the performance gaps in their own healthcare system and must close these gaps with a comprehensive approach
• Hospitals should set a goal date including measurable quality indicators and milestones
• The hospital’s budget for the plan needs to be evaluated by the governance boards
• The plan needs to be endorsed by clinical and safety leadership

Practice Plan

• Create a multidisciplinary team dedicated to glycemic management and best practices
• Develop a systematic approach to reducing severe hypoglycemia by identifying events and prioritizing them in order to raise institutional awareness and educate the hospital staff
• Implement Foundational Best Practices and “Just Do Its”
• Investigate glycemic events and collect causative factors such as insulin stacking and insufficient glycose monitoring
• Share strategies and implement informed interventions on target floors and patients.

Technology Plan

• Implement for insulin therapy recommendation
• Implement real-time surveillance method for informatics alerts
• Implement an automated hypoglycemia event analysis tool
• Implement point-of-care blood glucose monitoring and reporting systems to include quality insurance reports
• Implement automated triggers for most common causative factors of hypoglycemia
• Implement a results dashboard for each nursing unit within the hospital to resolve hypoglycemic events
• Set restrictions for prescribing insulin to only specialists