Tube feeds stopped after insulin administration

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Thu, 09/22/2016 - 13:07
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Ann Jankiewicz
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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

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