Tube feeds stopped after insulin administration

PLEASE NOTE:   Posts made to this forum should not be considered as the expressed opinions of, nor should be considered endorsed by, the Medication Safety Officer’s Society (MSOS) or the Institute for Safe Medication Practices (ISMP). 

Make sure your email is up-to-date
In order to continue to receive updates from MSOS, as well as forum posts and other valuable information as a member of MSOS, please be sure to update your email address with us, whenever it changes. If you need assistance doing so, please send an email to jrufo@ismp.org

1 post / 0 new
Ann Jankiewicz
Ann Jankiewicz's picture
Offline
Last seen: 2 days 18 hours ago
Joined: 12/11/2015 - 14:57
Tube feeds stopped after insulin administration

We have an order set for insulin that contains orders for hypoglycemia treatment and also an order for D10 for hypoglycemia prevention. If the patient receives NPH insulin and continuous tube feeds are later stopped, the nurse is to hang D10 at the same rate as the feeding rate. The D10 order may be placed days before the tube feeds are stopped for procedure or other reason. Our nurses are not hanging the D10 in all cases and we see 1-2 safety events each month for hypoglycemia due to this.

Do you have a similar workflow?
Do you see safety events for not following this workflow?
What has worked to prevent these omission errors?

Thank you,
Ann Jankiewicz, PharmD, BCPS, FASHP
Medication Safety Officer
Rush University Medical Center
Chicago, IL

Tags: