Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children

Pediatrics. 2016 Jul;138(1):e20151404. doi: 10.1542/peds.2015-1404. Epub 2016 Jun 17.


Objective: Insulin is a commonly used, high-risk medication in the inpatient setting. Incorrect insulin administration can lead to preventable hypoglycemic events, which are a significant morbidity in inpatient diabetes care. The goal of this intervention was to decrease preventable insulin-related hypoglycemic events in an inpatient setting in a tertiary care pediatric hospital.

Methods: Methods included the institution of several interventions such as nursing and physician education, electronic medical record order sets, electronic communication note templates, and the development of new care guidelines.

Results: After the institution of multiple interventions, the rate of preventable hypoglycemic events decreased from 1.4 preventable events per 100 insulin days to 0.4 preventable events per 100 insulin days.

Conclusions: Through the use of a multi-interventional approach with oversight of a multidisciplinary insulin safety committee, a sustained decreased rate of severe preventable hypoglycemic events in hospitalized pediatric patients receiving insulin was achieved.

MeSH terms

  • Adolescent
  • Child
  • Child, Preschool
  • Female
  • Hospitalization*
  • Hospitals, Pediatric
  • Humans
  • Hypoglycemia / chemically induced
  • Hypoglycemia / prevention & control*
  • Hypoglycemic Agents / administration & dosage*
  • Hypoglycemic Agents / adverse effects
  • Infant
  • Insulin / administration & dosage*
  • Insulin / adverse effects
  • Male
  • Practice Guidelines as Topic
  • Quality Improvement*
  • Retrospective Studies
  • Severity of Illness Index
  • Tertiary Care Centers
  • Treatment Outcome


  • Hypoglycemic Agents
  • Insulin