Adult Standardised
Subcutaneous Insulin
Prescribing Chart
August 2013
Case for Change
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Insulin is a high risk medication
Reported in top 10 high alert medicines worldwide
Nearly 3000 incidents in IIMS
Variation in insulin charts, charting; prescription,
administration and documentation
Variation in access to specialist services and glycaemic
management guidance
Mobile workforce
Need to improve management and patient safety
Risk minimisation for patients
Methodology
• Review of NSW and national charts
• Widespread clinical input
• Developed standardised chart
• Pilot - Ryde and Royal Prince Alfred
• State wide consultation - parallel to State Forms process
• Chart revised
• Endorsed by Medication Safety Expert Advisory
Committee (MSEAC)
What does it mean for me?
• Separate chart from NIMC
• Use in adult acute inpatient settings
• Intravenous and specialty charts - unchanged
• Document and use differently
• All glycaemic information linked:
• Prescription and administration
• Easier referral to readings
• Access to best practice guidelines; at bedside
• Standardised chart = standardised practice;
communication, documentation and interpretation
• Better patient care
Key principles
• Combined monitoring and
guidelines - minimise delay in
management decisions
• Clinicians without local guidelines
have clear guidelines for:
- Insulin prescription
- Insulin administration
- Management of hypo and
hyperglycaemia
- Safe use of supplemental insulin
• Do not take the place of local
guidelines or policies
• Reduced risk of error
Four Sections
• Page 1, including top of page 3:
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Patient Identification and demographics
Alerts
Codes for not administering
Instructions
Guidelines for prescription and administration
Special instructions
• Page 2 and 3:
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Regular, supplemental, once only and telephone orders
BGL and ketone monitoring
• Page 4:
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Guidelines for glycaemia management
Patient Identification and demographics
• All charts require ID label affixed consistent with NIMC
‾ MRN
‾ Name (family and given)
‾ Gender
‾ DOB
‾ Medical Officer (MO)
‾ Address
‾ Location
Allergies and Adverse Drug Reactions
(ADR)
• Clinical staff to complete Allergies and ADR
• Select Nil Known, Unknown or;
• If allergy exists document:
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Name of drug/substance
Reaction details
• Person documenting required to:
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Sign
Print name and;
Date the entry
Alerts
• Prescriber document
who to notify if certain
criteria met e.g. BGL or
ketones out of range
• If no alerts select Nil
• All entries signed and
dated
• If alert changed- cross out, sign and date it and enter new
alert
• Enter details in health care record
Reason for not administering
• Complete when unable to administer
insulin
• Codes to be circled
• If dose refused, notify prescriber
• If withheld, document reason in health
care record
• If not available - obtain supply or contact
prescriber
Instructions
• The chart is used for:
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All insulin prescriptions, except IV
Recording BGL and ketones, for patients on subcutaneous
insulin
• Specify frequency of monitoring (page 3)
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Unstable BGLs require more frequent monitoring
• All patient management must also be documented in
health care record
Guide: Prescription & Administration
• Daily review and prescription recommended:
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May order ahead if glycaemic status stable
Modify requirements - Peri-operative and modified diets
Target BGL range 5-10mmol/L, except pregnancy
Do not re - write units, it is pre printed
Orders:
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No alterations to original order
Discontinue by line through insulin name, 2 oblique lines in
administration column on day of discontinuation, sign and date
• Abdomen is preferred injection site
Additional information and instructions
• Indicate if patient is on:
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Insulin pump
Other diabetes medication
• Special instructions:
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To communicate information at bedside e.g. supervise using
insulin pen
Can be completed by any staff member
NB: All patient management must also be documented in the patients
health care records
• Daily orders- may be in advance if stable
• Regular subcutaneous orders must contain:
‾ Type of insulin
‾ Date prescribed
‾ Frequency
‾ Time of administration
‾ Dose
‾ Prescriber’s signature and name printed
‾ Prescribers contact
• Administration record must contain:
‾ Time given
‾ Initials of administrator
‾ Initials of 2nd person checking
• Before administering regular insulin check if
supplemental insulin is ordered and needed
NB: Two staff to initial and record time given,
one of which must be a registered nurse
Supplemental Insulin
• Guidelines page 4
• Daily review and adjustment of regular insulin during
acute phase of illness
• Not a replacement for regular insulin doses
• Best given before a meal, in addition to usual insulin
• If repeated doses needed - consider adjustment of regular
doses
• Prescribed based on preferred range in space provided
Supplemental Insulin
prescription
• Order must contain:
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Type of insulin
Date prescribed
Time of administration- before meals or specify
Dose for each BGL threshold
Prescribers signature, name and contact
Supplemental Insulin
• Administration record must contain:
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Date
Time
Dose
Initials of administrator
Initials of 2nd person checking
NB: One nurse must be a registered nurse
administration
Page 3
• Blood glucose and ketone monitoring
- Frequency selected
- Hypo record and treatment comments (right hand side)
• Once only subcutaneous insulin (bottom)
• Telephone orders
- 4 Most be signed within 24 hrs
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Patients on subcutaneous insulin only
Frequency indicated by tick box
BGLs - relate to day of insulin administration
Hypoglycaemia section- extra BGL and action columns,
record episodes and treatment
NB: All hypoglycaemic episodes should be managed
immediately & include assessment for clinical review and
must be fully document in health care record
Once Only S/C Insulin
• Specify date and time dose to be administered
• Nursing staff must initial and record time insulin
administered
Telephone Orders
• As per NSW Health policy
• Refer to local policies
• Signed within 24 hrs by MO
Page 4
• Guidelines for:
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Management of hypoglycaemia
Management of hyperglycaemia
Use of supplemental insulin and correction of
hyperglycaemia
• For areas without local guidelines, policy or specialist
support
• Don’t take the place of local guidelines or policy
Acknowledgements
• Inpatient Management Working Group
• The many clinicians who have contributed to development
and pilot of the Subcutaneous Insulin Medication Chart
Questions, Comments,
Observations….
Contact
Rebecca Donovan
PH: 9464 4626
Rebecca.Donovan@aci.health.nsw.gov.au
Melissa Tinsley
PH: 9464 4653
melissa.tinsley@aci.health.nsw.gov.au
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