One Step at a Time: Addressing Hypoglycemia Adverse Drug Events by Improving Insulin Management Through Rapid Cycle Improvement and Spread Process

After several monthly reviews of reported adverse drug events, hypoglycemia ranked highest for the hospital. Upon further review, the majority of hypoglycemic events were associated with the use of insulin, a high-alert medication. In fall 2011, a multidisciplinary team was created to develop a standardized diabetes order set and hypoglycemia treatment protocol and update an outdated diabetes flow sheet.

Despite the time and resources dedicated to these efforts, there was little to no adoption of new standardized processes. Hypoglycemic events remained unchanged. The hospital then de-escalated their approach to a unit specific pilot with continuous PDSA cycles and education on the floors by decentralized clinical staff pharmacists, nurse educators and clinical dietitians.

Three months later, hypoglycemic events have decreased by 34 percent.

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state. These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered

(The Institute of Medicine's six aims for improvement.)