A multifaceted approach in leveraging electronic health record tools for safe inpatient use of concentrated U-500 insulin
Abstract Disclaimer In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. Purpose The Institute for Safe Medication Practices classifies subcutaneous insulin as a high-risk medication. Concentrated U-500 insulin carries additional risks in comparison to conventional U-100 insulin, as the 5-fold more concentrated nature of this product, limitations to insulin pen dosing, and various devices for dose measurement may lead to miscommunication of patient-reported doses, resulting in downstream errors in ordering, verification, or administration. We describe a multifaceted approach to leveraging technical tools within the electronic health record (EHR) for U-500 insulin use. Summary At Cleveland Clinic, the U-500 insulin use process evolved in a number of phases using EHR tools. Phase 1 included new clinical decision support and documentation tools during order entry, including a customized alert that fired during order entry recommending that the prescriber order a consult with endocrinology and requiring the prescriber to provide the patient’s home insulin measuring device and the source of the patient’s reported home dose. In order verification, a customized alert fired directing the pharmacist to contact the patient or patient’s nurse and validate the information provided by the prescriber. Phase 2 involved transitioning dispensing of patient-specific doses from tuberculin syringes to U-500 insulin syringes. Phase 3 transitioned to use of U-500 insulin pens and included automatic dose rounding of ordered doses down to the nearest 5 units, and an additional customized pharmacist alert intended for cost conservation was added to fire if the patient had a recent administration of U-500 insulin documented, directing the pharmacist to determine whether the nurse needed a new pen dispensed. Conclusion Cleveland Clinic successfully implemented customized tools and processes within the EHR pertaining to the prescribing, verification, dispensing, and administration of U-500 insulin.