2 Insulin Safety

Verify the order and product

Insulin is a high-alert medication: an error in insulin type, concentration, dose, timing, or route can cause serious harm. Use the current order and the organization's insulin and hypoglycemia protocols. Pause and clarify an incomplete or conflicting order before administration.

Before giving insulin, check the patient, insulin name, concentration, dose in units, route, and timing against both the order and the product. Do not assume that two insulin products are interchangeable or convert a dose to a volume without verification.

For example, if an order says only “insulin 12 units subcutaneously” while the available products are a U-100 vial and a U-500 pen, verify the exact product and concentration with the order or prescriber before administration. Use only a compatible device. Never share an insulin pen, even if the needle is changed.

Recognize insulin actions

Insulins differ in their usual roles and action profiles:

• Lispro is rapid-acting and often used for meal coverage.

• Regular insulin is short-acting and generally given earlier before a meal than rapid-acting insulin.

• NPH is intermediate-acting, usually has a noticeable peak, and is generally cloudy.

• Glargine is long-acting basal insulin and generally has no pronounced peak.

Action times vary by product and person. Check the specific product information and prescribed timing rather than relying on a memorized schedule.

Coordinate insulin with food and NPO care

Coordinate rapid-acting meal coverage with food availability and the patient's actual intake. If a glucose check is complete but a meal tray is delayed, do not give the full mealtime dose automatically; follow the order and facility protocol, and seek clarification if timing or intake is uncertain. Giving meal-coverage insulin without ensuring timely food intake can cause hypoglycemia.

When a patient is NPO, do not assume that all insulin should be stopped or continued unchanged. Verify the individualized plan: basal insulin is generally still needed, while mealtime insulin and correction dosing require adjustment according to orders and protocol. Increase glucose monitoring as directed. Reduced intake, procedures, and delayed glucose checks can increase hypoglycemia risk. For a person with type 1 diabetes, clarify an absent or unclear insulin plan promptly.

Match glucose monitoring to care

Glucose monitoring frequency depends on nutrition and treatment. For a patient who is eating, check glucose before meals; if the patient is not eating, check every $4\text{–}6$ hours as ordered. Use more frequent checks for intravenous insulin according to protocol; monitoring is often every $30$ minutes to $2$ hours under a validated protocol.

Do not use one monitoring schedule for every patient and insulin regimen. Continue monitoring during transitions from intravenous to subcutaneous insulin as directed by the patient-specific protocol.

Respond to hypoglycemia

For a person who is awake and can swallow safely, give $15\ \text{g}$ of fast-acting carbohydrate, recheck glucose after $15$ minutes, and repeat treatment if the glucose remains below $70\ \text{mg/dL}$ ($3.9\ \text{mmol/L}$), following the facility protocol. For example, a glucose reading of $62\ \text{mg/dL}$ ($3.4\ \text{mmol/L}$) calls for this initial response when the person is alert and able to swallow.

If the person cannot swallow safely or needs assistance, do not give food or drink by mouth. Use the facility's urgent hypoglycemia protocol, such as glucagon or intravenous glucose as appropriate. Document the episode and review the treatment plan to help reduce recurrence.

Transition from intravenous insulin

When transitioning from an intravenous insulin infusion to subcutaneous insulin, give the prescribed basal insulin about $2$ hours before stopping the infusion, using the patient-specific transition protocol. Subcutaneous basal insulin needs time to take effect; this timing helps reduce rebound hyperglycemia. Continue glucose monitoring as directed.

Prepare a safe discharge plan

Before discharge, reconcile the insulin plan and confirm that the patient has the correct insulin products, devices, supplies, instructions, and follow-up. Check for gaps in insulin or supply access and assess the patient's ability to follow the plan.

Provide clear instructions and use teach-back to check understanding of dosing, administration, glucose monitoring, and recognizing and treating hypoglycemia. Do not assume that the patient already knows how to use any insulin pen or should continue the preadmission regimen without review.

• concentrated insulin

• medication reconciliation