Solving insulin dosing errors: A common detriment to hospital care quality

40% of patients experience an insulin dosing error during their hospital stay, according to the 2017 National Diabetes Inpatient Audit.  This constitutes a significant patient safety issue. Insulin can cause harm when used in error, and the Institute for Safe Medication Practices (ISMP) has classified all forms of insulin (subcutaneous and IV) as high-alert medications.

The good news is that insulin dosing error rates are addressable. Medication errors were shown to vary by over 60 percentage points across hospital sites, highlighting the potential and opportunity for care improvement.


With data scattered throughout the EHR, oftentimes providers don’t have the time to gather all the glycemic care information they need to manage insulin dosing effectively, on a routine basis. This makes glycemic care management  time-consuming and inefficient, often leading to  unwanted clinical outcomes.

Tamrah’s Story: Using GlycemiCare to improve patient safety at Palomar Health

“We just started using the GlycemiCare intravenous insulin decision support tool and right out of the gate, it’s improved patient safety.”

With the Core Disease Workflow app, it takes us an average of 18 minutes, from when a patient’s blood sugar drops below 250 mg/dL to when that patient gets dextrose added to their IV. That’s a lot faster than what we were doing before. Now, the moment that blood sugar drops below 250 mg/dL, GlycemiCare sends me an alert.


Ms. Jennings is a Clinical Nurse Specialist in Diabetes Services at Palomar Health.

Tamarah Jennings, MSEd, MSN, APRN

All of us on the diabetes team review GlycemiCare before we round on our patients. It’s the easiest way to see what blood sugars are doing, what medications patients are on, how much insulin they’ve received, and whether it was given intravenously or subcutaneously. It used to take a lot more time and effort to get this information--we would have to dig around in the EMR to find it. Now it’s right there when we need it.

Before GlycemiCare, we used a calculator on the intranet. We would have to click out of the patient’s chart, go to the intranet, get our calculations and then log back into the EMR to chart the changes we were making to the drip or fluids. Now we can calculate IV insulin without ever leaving the patient’s chart. Yesterday, we had a hypoglycemic event and just by looking at my GlycemiCare dashboard, I understood immediately why it was happening. At the same time that I could see the blood sugar dropping, I could see the time points when insulin had been given and knew right away that two doses had recently been stacked.

GlycemiCare makes it easy to access everything I need in one place. Being able to quickly grasp blood sugar trends makes my clinic workflow more effective, and efficient.

Case Study