Improving insulin medicines reconciliation and glycaemic safety in frail hospitalised older adults

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 to ensure safe inpatient glycaemic management and continuity of care at discharge. This process is particularly challenging in frail older adults with multimorbidity and cognitive impairment during acute illness. This study evaluated baseline practice in insulin medicine reconciliation and glycaemic safety in older inpatients admitted to geriatric wards.

Methods

Baseline data were collected retrospectively.  All insulin-treated patients admitted to acute geriatric wards were included. Unit of analysis was ‘inpatient-week’ ie. combined data for a single patient over 1 week.  Outcome measures included documentation of pre-admission insulin regimens on the inpatient insulin prescription chart and medicines reconciliation record, incidence of hypoglycaemia and hyperglycaemia in the preceding 72 hours, and adherence to recommended responses, including repeat blood glucose monitoring, ketone assessment and corrective insulin prescribing.

Results

32 ‘inpatient weeks’ were analysed (n=17 patients). Pre-admission insulin regimens were documented on the insulin chart in 28% (9/32) and in medicines reconciliation records in 19% (6/32), with both sources documenting insulin in 3% (1/32). Hypoglycaemia occurred in 9% (3/32) of inpatient-weeks; none had a documented repeat glucose check (0/3). Hyperglycaemia occurred in 41% (13/32); ketones were assessed in 38% (5/13), and corrective insulin was administered in 31% (4/13). Overall, dysglycaemia occurred in 50% (16/32).

Conclusions

Significant gaps exist in insulin medicine reconciliation and dysglycaemia management in frail hospitalised older adults. These findings highlight an important and modifiable patient safety risk. Structured interventions to improve medication verification and standardise management of dysglycaemia may support safer inpatient diabetes care and improve transitions of care for older patients.