Improving insulin medicines reconciliation and glycaemic safety in frail hospitalised older adults: quality improvement project

Improving insulin medicines reconciliation and glycaemic safety in frail hospitalised older adults: a quality improvement project

Background

Insulin is a high-risk medication, and prescribing errors are a recognised cause of inpatient harm. Accurate medicines reconciliation of pre-admission insulin regimens is essential for safe glycaemic management and continuity of care, particularly in frail older adults with multimorbidity, cognitive impairment and acute illness. This quality improvement project evaluated insulin medicines reconciliation and glycaemic safety practices on geriatric wards within a large tertiary hospital and assessed the impact of a multifaceted educational intervention.

Methods

A two-cycle quality improvement project was undertaken using inpatient-weeks as the unit of analysis for insulin-treated patients admitted to geriatric wards. Outcome measures included documentation of pre-admission insulin regimens on insulin prescription charts and medicines reconciliation records, incidence of hypoglycaemia and hyperglycaemia within the preceding 72 hours, and adherence to recommended management, including repeat glucose monitoring following hypoglycaemia and ketone assessment during hyperglycaemia. Following baseline data collection, a multifaceted educational intervention was introduced comprising a ward-based diabetes safety poster with QR code access to local diabetes guidelines, a departmental diabetes teaching session, and presentation of baseline findings at a geriatric quality improvement showcase before re-audit.

Results

Cycle 1 included 55 inpatient-weeks and Cycle 2 included 44. Documentation of pre-admission insulin regimens improved substantially on insulin prescription charts from 27.2% to 90.9% (15/55 vs 40/44) and on medicines reconciliation records from 25.5% to 54.5% (14/55 vs 24/44). Hypoglycaemia remained uncommon (10.9% vs 9.0%), while repeat glucose monitoring within 15 minutes improved from 0% (0/6) to 50% (2/4). The proportion of patients experiencing hyperglycaemia remained unchanged (36.4% in both cycles), but ketone assessment improved from 55.0% (11/20) to 93.8% (15/16).

Conclusions

A simple, low-cost, multifaceted educational intervention was associated with marked improvements in insulin medicines reconciliation and adherence to recommended management of dysglycaemia in frail hospitalised older adults. Although the prevalence of dysglycaemia was unchanged, substantial improvements in documentation and clinical management suggest enhanced inpatient diabetes safety. These findings demonstrate that a low-cost, easily reproducible educational intervention can improve insulin safety processes and has the potential to be adopted across geriatric inpatient services.