Patient safety and inpatient glycemic control: translating concepts into action

(1) To summarize current knowledge regarding patient safety issues and their impact on inpatient glycemic control and (2) to provide a systematic and practical approach to improving patient safety in this area.

Insulin delivery in inpatient settings is examined, as are the barriers to safe insulin therapy. A distinction is made between safety strategies of proven value and those that are less useful. Characteristics of safer insulin algorithms are discussed.

Errors in insulin administration remain a common cause of injuries. Despite strong evidence of the dangers of sliding-scale insulin regimens in inpatient settings, sliding-scale insulin regimens remain a widely used but ineffective (and occasionally dangerous) method. To correctly analyze inpatient processes of care, a systems approach is needed, and the relationship between quality of care, latent medical errors, injurious patient errors, and patient safety must be understood. In complex systems such as hospitals, catastrophic error has complex roots involving many individuals, and the design of the system often has latent flaws that make human error likely, even predictable. The concept of the scope of awareness is useful in understanding why it is ineffective to focus only on those at the point of care, and how improvement is more apt to occur with a team approach and the evaluation of systemic factors, at the "blunt end" of care. Error-prone organizations are often very unsafe, and certain practices tend to be common among them. Data are now available showing the negative impact of poorly supervised trainees and the extent of the problem worldwide on patient safety.

Redesign of patient care provided in hospitals regarding glucose control is long overdue. Practical strategies are given that focus on improving patient safety for the patient needing inpatient glycemic control. Such techniques now have a sufficient evidentiary base. Therefore, hospitals should move rapidly to make euglycemia a goal for all inpatients, and to make patient safety in glycemic control a reality, not just for a few, but for all patients in our care.