R E V I E W S & A N A LY S E S Point-of-Care Technology: Glucose Meter’s Role in Patient Care Lea Anne Gardner, PhD, RN INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority Point-of-care (POC) glucose meters are an integral part of the typical approach to manag- ing hospitalized patients’ blood glucose levels1,2 because they provide immediate results and are cost-effective. Used correctly, these devices are an invaluable aid; however, they are not infallible. Taking action solely on the basis of the glucose meter results without a patient assessment can lead to serious unintended consequences. The following event ABSTRACT reported to the Pennsylvania Patient Safety Authority demonstrates this point: Glucose meters are a point-of-care A patient’s [glucose meter result] read “RR HI.” The patient was asymptomatic and device used in the management of previous [glucose meter results] were not running “HI.” Insulin coverage was held until blood glucose levels for hospitalized the result of the [laboratory] glucose [level] was obtained. The [laboratory] glucose result patients. Glucose meters provide results read 79. The patient was not given any insulin coverage and remained asymptomatic so quickly that, in some cases, health- with low glucose [levels]. care workers treat patients based on meter results before validating them. The purpose of this review is to identify problems related to POC blood glucose testing Events reported to the Pennsylvania in Pennsylvania hospitals and provide suggestions to prevent adverse events. Patient Safety Authority demonstrate unintended consequences that arose PROBLEMS WITH POC BLOOD GLUCOSE TESTING when patients were treated based solely A search of the Authority reporting system database, from June 28, 2004, through May on glucose meter results. Proper meter 31, 2011, was conducted to identify glucose-meter-related event reports. The initial search, use, hospital policies and protocols, using the words “test strips,” “glucose strips,” and “accucheck,” identified more than and a physical assessment coupled 3,200 event reports, which were refined to more than 1,300 reports by limiting the search with effective communication are to specific event types (e.g., procedure errors and complications, equipment use and components of good patient care. The device issues, miscellaneously identified glucose-meter-related reports). A review of the ability to think critically, balancing these 1,300 reports identified 71 glucose meter near-miss and adverse event reports that com- components, can be the difference posed the final data set. The detailed analysis identified four common themes, as follows: between the delivery of safe patient — Equipment use care and a serious or fatal adverse event. (Pa Patient Saf Advis 2011 — Hospital policy and protocols Dec;8[4]:119-125.) — Physical assessment of the patient — Healthcare team communication Seventy percent (n = 50) of the 71 reports document equipment use as the only issue, while the remaining 30% (n = 21) of the reports identified an equipment use issue in conjunction with 1 or more of the 3 other issues identified above, (e.g., equipment use and hospital policy; equipment use, hospital policy, and physical assessment). (See Table 1.) Next, the analyst examined harm score event report categories.3 Fifty-four percent (n = 38) of the reports were reported as harm scores A through C (an event did not reach the patient, or an event that reached the patient but did not cause harm or require increased monitoring). Forty-six percent (n = 33) of the reports were reported as harm scores D through I (the event reached the patient and required monitoring intervention or caused harm or death). Harm scores D through I were present whether there was only one issue (i.e., equipment use) or multiple issues reported. Equipment Use Results from blood glucose meters are not as accurate as lab-based blood glucose results.4-6 The Authority data analysis identifies two types of glucose meter issues: ques- tionable glucose meter results and test strip issues. Standards set by the U.S. Food and Drug Administration (FDA) and the International Organization for Standardization require that 95% of glucose meter results vary no Vol. 8, No. 4—December 2011 Pennsylvania Patient Safety Advisory Page 119 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table 1. Glucose-Meter-Related Events Reported to the Pennsylvania Patient Safety Authority, June 28, 2004, through May 31, 2011 HOSPITAL POLICY PHYSICAL ASSESSMENT HEALTHCARE TEAM TOTAL NUMBER EQUIPMENT USE AND PROTOCOL OF THE PATIENT COMMUNICATION OF REPORTS  50   9   5    3    2    1     1 71 more than 20% (±20%) when glucose lev- done to the machine and an out-of- physiologic conditions. The following is els are greater than 75 mg/dl. This means order sign was placed on the machine. an Authority report example: that when a blood glucose level reads 100 A patient’s blood sugar was checked The nursing supervisor received a mg/dl, 95 of 100 samples should read using a [glucose meter]. The lunchtime call from the community [outpatient] between 80 and 120 mg/dl.4,5 The other result was 517. A [blood glucose test] peritoneal dialysis [nurse] about a 5% of results may fall just outside the was [immediately] retaken to check for patient being directed to the ED. The 20% range or may be extreme outliers. accuracy, and the result was greater peritoneal dialysis nurse called the The magnitude of this issue was presented than 600. A blood [laboratory] level ED nurse to report the patient was at an FDA public meeting. A physician check was conducted per protocol, and on extraneal/icodextran peritoneal reported that at his hospital he had the [lab] glucose [result] was 136. The dialysis solution, and that [certain] 600,000 glucose meter results per year; nurse used the serum glucose as the blood glucose machines cannot be if 95% of the results fall within the 20% actual result and reported a malfunc- used [on patients receiving certain variability, the other 5% or 30,000 results tion in the machine to the lab and the types of peritoneal dialysis] or false fall outside the acceptable range.5 [nurse manager]. The [nurse manager] readings will occur [because certain An analysis of the Authority data was con- was made aware of the situation and types of test strips cannot distinguish ducted to determine the type of glucose took the glucose meter out of use on between glucose, maltose, galactose, meter variability within Pennsylvania hos- the floor and notified the supervisor in and xylose]. The peritoneal dialysis pitals. There are three types of variability: the lab. The supervisor in lab removed nurse requested this information high-blood glucose results (72%, n = 51), the machine from service and replaced be placed on the patient chart and unidentified questionable results (18%, the machine with a new machine. reported to the floor nurse. Only [lab] n = 13), and low-blood glucose results Test strips are the second issue. Glucose blood glucose [tests] can be performed (10%, n = 7). The analyst then evaluated meter test strips are layers of porous on the patient. [Glucose meter results] whether the high-blood glucose results paper with enzyme reagents that react to were done [over a 24-hour period]. were validated, how they were validated, substances, using whole blood to calcu- [On the second day,] … [a glucose and where they occurred (see Table 2). late a blood glucose result.6,7 Test strips meter result] was done and results The following two Authority reports dem- require careful handling because they appeared normal. A serum blood onstrate the significance of high-blood can absorb and react to different types was drawn … and the [lab] blood glucose meter results: of nonblood substances (e.g., food, mois- glucose was 32. …. All unit managers ture, nonglucose sugars), leading to test involved were made aware. Orders The nightly [glucose meter] reading were changed to reflect serum blood was 454. [Staff] obtained a stat strip contamination. Other commonly reported problems associated with test glucose [lab tests] only and a note was blood glucose from the lab. The [lab placed on the front of the chart. result] was 152. A quality check was strips include improper use and patient Page 120 Pennsylvania Patient Safety Advisory Vol. 8, No. 4—December 2011 ©2011 Pennsylvania Patient Safety Authority Table 2. Validation Technique and Event Location (n = 51) of High Glucose Meter Result results was conducted to determine the Events Reported to the Pennsylvania Patient Safety Authority, June 28, 2004, through occurrence of insulin-induced hypogly- May 31, 2011 cemia. Twenty-seven percent (n = 14 of AUTHORITY HIGH GLUCOSE NUMBER PERCENTAGE 51) of patients with high meter results METER RESULT REPORTS OF REPORTS OF REPORTS were administered insulin; four patients subsequently experienced hypoglycemic Validation Technique symptoms or were treated with dextrose Compared to blood serum lab value 44 86.3% 50%. See the following reported example: Check result with same or different 6 11.8 Patient’s glucose meter reading [prior glucose meter to lunch] read “HI.” Patient covered Not validated with glucose meter or 1 1.9 with 6 units Novolog insulin. A stat serum lab venous draw was done; [the result] Location of Event was 62. The patient was lethargic at Units other than intensive care units 36 70.6 this time and was given orange juice with sugar. [Repeat glucose meter Not specified 10 19.6 result] came up to 156. Intensive care units 5 9.8 Healthcare Team Communication Delays Hospital Policy and Protocol an existing condition. Before treating a Miscommunications, lack of commu- Challenges patient’s high glucose level, especially a nication, or partial communication of Hospital policies and procedures dictate new high glucose level, the result needs to information were reported in only 7% how blood glucose meters are used. The be validated. Hospital policies and proto- (n = 5 of 71) of the reports; see the follow- Authority event descriptions that men- cols can guide staff in the proper response ing example: tion patient treatment delivered based to this situation. A routine [glucose meter test] was per- on glucose meter results were a proxy for formed with a result of 520. The lab hospital policy and protocols. Twenty-one Physical Assessment Symptoms was called to draw a blood glucose percent (n = 15) of the reports implicated Hyperglycemia is more likely to occur level. The patient was [treated] with hospital policy or protocols. when patients are experiencing a sym- 10 units of Novolog subcutaneous. The following example demonstrates the pathetic response to physiologic stress. The [blood glucose] result was 375. impact of hospital policies on how blood The challenge for healthcare workers is A [glucose meter test was performed] glucose meters are used: to distinguish actual hyperglycemic states one hour later after administration from inaccurate meter results. When of the insulin. The insulin coverage A [glucose meter] gave a reading of interpreting a high blood sugar reading, 468, and the physician was notified was given to the patient prior to lab it is important to consider the clinical verification, which could have been and ordered insulin, which was given. context. For example, has the patient The morning [fasting blood sugar] detrimental to the patient. been experiencing similar levels of hyper- from lab came back with result of glycemia? Has he or she just eaten or This report demonstrates the importance 122. A [glucose meter test] was redone taken sugar containing fluids? Has the of obtaining more detailed information, on a different machine with a reading patient just been started on steroids? Was the lab glucose level, before any treatment of 135. [The second glucose meter] a dose of insulin omitted? High glucose decisions. was calibrated [within normal limits] meter results accompanied with a physical following the discrepancy. [The initial assessment help validate the results and WAYS TO SAFELY INCORPORATE glucose meter] machine was taken out reduce the likelihood of patients devel- GLUCOSE METER USE INTO of service. The patient’s [blood sugar] oping hypoglycemia from inappropriate CLINICAL PRACTICE was checked [on the hour for six hours] treatment. Nine of the 51 high glucose and observed for hypoglycemia. No meter readings (13%) identified whether Equipment Use adverse outcome was observed. patients exhibited or were subsequently Questionable glucose meter results can This report does not indicate whether evaluated for symptoms of hypoglycemia. occur because of meter variability, user the result was a new high glucose level or A separate analysis of high glucose meter variability (e.g., sample quality, timing), Vol. 8, No. 4—December 2011 Pennsylvania Patient Safety Advisory Page 121 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S patient physiology, care of the meter, and Glucose meters use enzymes (glucose — Improper storage of the test strips test strips. The following measures (based oxidase, glucose hexokinase, or glucose (e.g., exposure to heat, moisture, on literature and analysis of reports) can dehydrogenase) and an indicator (pyrrolo- light)4,12,13 reduce the chance of questionable glucose quinolinequinone or nicotine adenine — Improper handling of test strips (e.g., meter results: dinucleotide) to calculate results.10 sugary foods such as bananas or fruit — Perform quality checks at the begin- Glucose meters that use the glucose juice on hands can contaminate the ning of every shift. dehydrogenase pyrroloquinolinequinone strips)4,7 (GDH-PQQ) enzyme testing method can- — Use of outdated strips7,9,12 — Stay informed about the patient’s not distinguish between glucose, maltose, blood glucose result history and — Improper blood sample collection4 galactose, or xylose.10 GDH-PQQ devices activities. — Inadequate blood sample size4 used in the wrong patient population can — Use the same glucose meter for the lead to fatal results.11 Patients susceptible The following strategies can help maintain same patient all day.8 to GDH-PQQ enzyme indicator problems test strip validity: — Place a clearly marked identification include those receiving peritoneal dialysis — Follow the Centers for Disease number on each glucose meter. solutions containing icodextrin, certain Control and Prevention clinical labo- — Record the glucose meter identifica- types of immunoglobulin therapy, or ratory improvement advisory rules tion number in the patient’s chart to other drugs containing maltose, galactose, and regulations for assuring meter/ ensure that the same glucose meter is or xylose.7,10,12 (See “GDH-PQQ Test Strip testing accuracy.14,15 used on the same patient throughout Implementation Strategies” exclusively — Consider the presence of physiologic the day. available on the Authority website.) conditions (listed above) when assess- — Perform a separate or additional glu- The following are other physiologic condi- ing the validity of an unexpected cose meter reading at the same time tions that can invalidate glucose meter result. as the glucose serum blood draw results: — Perform quality checks on the each day to validate the blood glu- machine and test strips at the begin- — Hematocrit (low levels can falsely cose result with the serum lab value. ning of every shift, especially if the elevate results; high levels can falsely — If a glucose meter is dropped, check lower results)12 meter is used on multiple patients the manufacturer’s protocol and run each day. — Dehydration, hypotension, and test strips with the appropriate con- Check that test strip and control lot hyperosmolar states — trol solution.9 numbers have been correctly entered — Oxygen levels (both low and high — Clean meters at regular intervals into the meter.9 oxygen levels can affect results) and whenever visibly dirty, follow- — Read and follow manufacturer ing the manufacturer’s instructions — Perfusion rates (changes in perfusion rates, such as a shock state or post instructions on proper use and stor- and facility policy. Dirty optics and age of test strips.9 inappropriate cleaning products can exercise, can influence results)4,9 Two types of therapies can invalidate glu- — Ensure proper storage of test strips; produce invalid results.9 cose meter results, as follows: do not expose to heat, light, or — Check the meter for check battery or humidity.4,13 replace battery messages.9 — Uric acid and vitamin C can — Wear gloves to prevent contamina- — Follow hospital policies for confirm- interfere with blood glucose meter tion due to food or sugar residue on ing questionable results.9 measurement.9 hands. — Avoid squeezing the finger to obtain — High levels of drugs such as acet- — Use all test strips in a bottle before a drop of blood. Fluid from the sur- aminophen or salicylate acid can opening a new bottle. rounding tissue can mix with the affect results.4 — Do not combine old test strips in a blood sample and affect test results.9 The second problem with meters is the bottle of newly opened strips. Sources of test strip error come from the test strips. Special care is required to maintain their precision. Many different — Use a permanent marker to label enzyme testing technology and the test actions can invalidate test strip accuracy, bottles of test strips and control solu- strips. There are ways to avoid invalid glu- including the following: tion with the date and time opened. cose meter results that include knowing the limitations of certain types of enzyme — Incorrect entry of the test strip lot or testing glucose meters and ensuring the calibration code4,7,12 proper care and handling of test strips. Page 122 Pennsylvania Patient Safety Advisory Vol. 8, No. 4—December 2011 ©2011 Pennsylvania Patient Safety Authority — Document the control solution expi- This could have been detrimental to meter and received] a reading of 112. ration date after opening. the patient if policy was followed. The physician was made aware [of — Check test strip and control solution Rather than follow hospital policy and the results]. The patient was asymp- expiration dates.4 treat the patient based on the glucose tomatic. An order was received to give meter result, the individual withheld treat- an evening snack and to use the result Hospital Policy and Protocol ment until a lab result invalidated the of 112 as the patient’s [glucose level]. Refinement result. This decision was beneficial since A physical and mental assessment can Blood glucose meter use in the hospital the patient’s serum lab glucose result validate hyperglycemic or hypoglycemic setting is an accepted practice.1,2 What was normal. glucose meter results. Hyperglycemic hospitals may not be aware of is an FDA Another report demonstrates the impor- patients can experience polydipsia recommendation regarding inpatient tance of hospital policies: (increased thirst), polyuria (increased uri- hospital glucose meter use clearance. In nation), and sugar in the urine. In cases 2009, FDA wrote a letter to the president A [patient’s] blood sugar was reported of extremely high blood glucose levels of the American Association of Clinical as 480 from the machine. Per policy, (i.e., greater than 240 mg/dl), urine needs Endocrinologists in response to concerns 16 a venipuncture blood sugar was drawn to be checked for ketones to determine about blood glucose testing meter perfor- for a new high. The patient was whether the patient is in diabetic ketoaci- mance. The letter addresses hospital uses treated with [sliding scale] coverage as dosis. Symptoms of ketoacidosis include of self-monitoring blood glucose (SMBG) ordered. The blood sugar came back shortness of breath, breath that smells devices, stating: at 158. The machine was removed fruity, nausea and vomiting, and very from service to be checked. All follow- dry mouth.17 FDA has cleared laboratory-based up [glucose meter results were within and bench-top point-of-care normal limits] for the patient. Hypoglycemia is a condition that requires devices that provide accurate immediate attention because it can be glucose test results with a fast Hospital policies and protocols that fatal if left untreated. Hypoglycemic turnaround time. Meters such anticipate alternative scenarios, such as symptoms include hunger, shakiness, as the HemoCue Glucose 201 withholding insulin until lab results are nervousness, sweatiness, sleepiness, RT system and the i-Stat system, received, guide staff when questionable irritability, light-headedness, fainting, which are not test strip based situations arise. Hospital policies can be unresponsiveness, coma, and death. Hypo- technologies, have accuracies written in ways that empower staff to glycemia can also cause symptoms when approaching those of laboratory consider alternative actions, when neces- sleeping, including crying out or having methods. Nevertheless, many hos- sary. (See “Hospital Policy Measures to nightmares, finding pajamas or sheets pitals continue to use SMBG [test Ensure Appropriate Use of Blood Glu- damp from perspiration, and feeling tired, strip based] devices, cleared only cose Meters.”) irritable, or confused after waking up.18 as aids in the management of dia- Not all patients are symptomatic. Careful betic patients, in these settings, Physical Assessment Evaluation and close monitoring is necessary to accu- even though they are not FDA Patient care is not to be based on rately identify the patient’s condition and cleared to diagnose disease or to POC glucose meter results alone. Quality respond appropriately. maintain tight glycemic control of bedside patient care includes a physical diabetic and non-diabetic patients and mental assessment. The following Effective Healthcare Team in the hospital environment. This report demonstrates the value of a physi- Communication practice can be problematic. cal assessment to validate glucose Effective communication provides appro- This FDA concern is underscored in this meter results. priate situational information, including event reported to the Authority: The patient’s evening [glucose meter any pertinent background information, a [Glucose meter] read high on patient result] read “hi.” A [second glucose physical assessment, and any test results mentioned before. I obtained a stat meter result] was rechecked and read upon which to base care.19 blood glucose reading before covering “hi.” A stat [laboratory] glucose was The following general actions can improve my patient with the highest dose of drawn. The result was 58. The [staff] communication: coverage with Novolog. The blood spoke with the lab, which ran the [test] twice and [received] the same — State the situation succinctly, includ- glucose reading came back only 91. ing pertinent background and results. A third [glucose meter test] was done using a [different glucose physical assessment information.19 Vol. 8, No. 4—December 2011 Pennsylvania Patient Safety Advisory Page 123 ©2011 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S HOSPITAL POLICY MEASURES TO ENSURE APPROPRIATE USE OF BLOOD GLUCOSE METERS The following 10 measures are suggestions to add to current address withholding treatment of questionable blood hospital blood glucose meter policies and protocols: glucose meter results until the serum lab value results are known. 1. Consider facility-wide use of one type of blood glucose meter. It will decrease staff confusion and increase learn- 10. Consider a hospital policy that requires stat glucose lab ing as staff shares experiences, problems, and potential value results should be completed and available in a clini- solutions.1 cally reasonable time frame, preferably 30 minutes to no longer than 1 hour. 2. Consider certification and recertification of healthcare personnel to use blood glucose meters, especially those 11. When questionable results arise, take the following performing routine quality control. actions: 3. Provide routine education in the appropriate care and use a. Check the last time a quality check was done. of blood glucose meters and test strips. b. Check the meter for cleanliness.3 4. Blood glucose meters are cleared only as aids in the c. Check the meter batteries and test strips.3 management of diabetic patients in hospital settings and d. Obtain a different meter to compare results. should be used as an aid. Blood glucose meters are not e. Draw a serum lab value and withhold treatment until cleared by the U.S. Food and Drug Administration to results are available. diagnose disease or to maintain tight glycemic control of diabetic and non-diabetic patients in the hospital f. Perform a patient physical assessment. environment.2 g. Communicate the situation with physician. Provide a comprehensive summary of the patient’s physical and 5. Perform a separate or additional blood glucose meter test mental status, the glucometer reading, and any other daily at the same time as a lab serum glucose draw to meter-related issues, serum lab value, and past medi- compare and validate blood glucose meter results with cine and diet history. lab results. 12. When blood glucose meter results are in doubt, remove 6. Perform a quality-control check for each blood glucose the meter from patient care, and send it for servicing. meter at the beginning of each shift. Increased use increases the likelihood of inaccurate results (e.g., dirty Notes optics, dropping or bumping the machine, issues with the 1. Hoffman J. Glucose monitoring technology [online]. 2011 test strips). Jun 6 [cited 2011 Aug 5]. Available from Internet: http:// laboratory-manager.advanceweb.com/Archives/ 7. Place a hard stop (forced function) in the meter, if possible, Article-Archives/Glucose-Monitoring-Technology.aspx. to prevent use until a quality check is completed. 2. FDA’s Center for Devices and Radiological Health’s 8. Consider a hospital policy that requires staff to wear response [letter to Dr. Jeffrey R. Garber, MD, FACP FACE, , gloves when touching the test strips. President American Association of Clinical Endocri- 9. Consider a hospital policy that requires staff to draw a nologists] [online]. 2009 Jun 24 [cited 2010 Aug 19]. Available from Internet: www.nytimes.com/packages/pdf/ serum lab value when questionable results arise (i.e., health/20090717_MONITOR_1.pdf. newly unexpected high blood glucose meter results) or when glucose meters are used in settings that increase 3. ECRI Institute. Using blood glucose meters: minimizing the likelihood of invalid results (i.e., specific physiological errors, maximizing accuracy [guidance article]. Health conditions as identified in the main article). The policy can Devices 2004 Jul;33(7):251-6. — Inform appropriate individuals and all — Use correct terminology, and provide — Allow the receiver to review the team members when plans change.19 explanations of ambiguous terms.20 information.20 — Speak clearly and simply, and repeat — Request and provide clarifications — Allow opportunity for questions back information to decrease com- as needed.20 and clarifications.20 munication errors.20 — Ensure statements are direct and unambiguous.20 Page 124 Pennsylvania Patient Safety Advisory Vol. 8, No. 4—December 2011 ©2011 Pennsylvania Patient Safety Authority CONCLUSION based on measurements alone can lead to physician is essential before any actions Blood glucose management in hospital- serious and fatal patient events. Blood glu- are taken. The amount of time required ized patients is a multifaceted process cose meter results provide a starting point considering all aspects of the patient’s that requires critical thinking. Test results of inquiry about a patient’s health status. condition and the usual way to respond are one important measure of a patient’s A physical and mental assessment, along can be the difference between the delivery condition but should never be used as the with an evaluation of the patient’s of safe patient care and serious or fatal sole basis for treatment. Treating a patient previous history, are needed. As devia- patient events. tions arise, communication with the NOTES 1. Rodbard HW, Blonde L, Braithwaite SS, administration [online]. [cited 2011 Oct advisory rules and regulations [online]. et al; AACE Diabetes Mellitus Clinical 3]. Available from Internet: http:// 2004 Jul. [cited 2011 Nov 7]. Available Practice Guidelines Task Force. American www.cdc.gov/injectionsafety/ from Internet: http://wwwn.cdc.gov/clia/ Association of Clinical Endocrinologists blood-glucose-monitoring.html. regs/toc.aspx. medical guidelines for clinical practice for 9. ECRI Institute. Using blood glucose 16. Hamburg, Margaret A. (U.S. Food and the management of diabetes mellitus. Endocr meters: minimizing errors, maximizing Drug Administration, Commissioner Pract 2007 May-Jun;13(Suppl 1):1-68. accuracy [guidance article]. Health Devices of Food and Drugs) Letter to: Jeffrey R. 2. American Diabetes Association. Standards 2004 Jul;33(7):251-6. Garber (President, American Association of medical care in diabetes—2008. Diabetes 10. Icodextrin in peritoneal dialysis solution of Clinical Endocrinologists, Jacksonville, Care 2008 Jan;31(Suppl 1):S12-54. may cause falsely high blood glucose read- FL) [online]. 2009 Jun 24 [cited 2011 3. National Coordinating Council for ings [online]. Pa Patient Saf Advis 2008 Jun Aug 3]. Available from Internet: Medication Error Reporting and Preven- [cited 2011 Aug 3]. Available from Internet: www.nytimes.com/packages/pdf/ tion. NCC MERP index for categorizing http://patientsafetyauthority.org/ health/20090717_MONITOR_1.pdf. medication errors [online]. 2001 Feb 20 ADVISORIES/AdvisoryLibrary/2008/ 17. Frederick S, Danzl DF. Hyperglycemia, [cited 2011 Jul 28]. Available from Jun5(2)/Pages/64.aspx. Chapter 41. Metabolic & Endocrine Emer- Internet: http://www.nccmerp.org/ 11. Gaines AR, Pierce LR, Bernhardt PA. gencies. In: Stone CK, Humphries RL, eds. medErrorCatIndex.html. Fatal iatrogenic hypoglycemia: falsely Current Diagnosis & Treatment: Emer- 4. ECRI Institute. Blood glucose meters elevated blood glucose readings with gency Medicine, 6th ed. [online]. 2011 and patient safety: a new focus on perfor- a point-of-care meter due to a maltose- [cited 2011 Oct 10]. New York: McGraw- mance [guidance article]. Health Devices containing intravenous immune globulin Hill. Available from Internet: http://www. 2010 May;39(5):166-70. product [online]. U.S. Food and Drug accessmedicine.com/content.aspx?aID= Administration 2009 Jun 18 [cited 2011 3112365&searchStr=hyperglycemia#3112365. 5. U.S. Food and Drug Administration (FDA). FDA public meeting: Clinical accuracy Aug 2]. Available from Internet: http:// 18. National Institute of Diabetes and requirement for point of care blood glucose www.fda.gov/BiologicsBloodVaccines/ Digestive and Kidney Diseases. National meters [online]. 2010 Mar 16 [cited 2011 SafetyAvailability/ucm155099.htm. Diabetes Information Clearinghouse: Jul 9]. Available from the Internet: http:// 12. Nichols JH. Blood glucose testing in the Hypoglycemia [online]. [cited 2011 Sep www.fda.gov/downloads/MedicalDevices/ hospital: error sources and risk manage- 29]. Available from Internet: http:// NewsEvents/WorkshopsConferences/ ment. J Diabetes Sci Technol 2011 Jan 1; diabetes.niddk.nih.gov/dm/pubs/ UCM208598.pdf. 5(1):173-7. hypoglycemia/index.aspx. 6. Wahl HG. How accurately do we measure 13. Bamberg R, Schulman K, MacKenzie M, 19. Leonard M, Graham S, Bonacum D. The blood glucose levels in intensive care unit et al. Effect of adverse storage conditions human factor: the critical importance of (ICU) patients. Best Pract Res Clin Anaes- on performance of glucometer test strips. effective teamwork and communication in thesiol 2009 Dec;23(4):387-400. Clin Lab Sci 2005 Fall;18(4):203-9. providing safe care. Qual Saf Health Care 7. Lunt H, Florkowski C, Bignall M, et al. 14. U.S. Centers for Disease Control and 2004 Oct;13(Suppl 1):i85-90. Capillary glucose meter accuracy and Prevention. Subpart A: general provisions. 20. Friesen MA, White SV, Byers JF. Chapter sources of error in the ambulatory setting In: Clinical laboratory improvement advi- 34 Handoffs: Implications for nurses [online]. NZ Med J 2010 Mar [cited 2011 sory rules and regulations [online]. 2004 in Hughes RG (ed.). Patient safety and Sep 29]. Available from Internet: Jul. [cited 2011 Nov 7]. Available from quality: An evidence-based handbook for http://journal.nzma.org.nz/ Internet: http://wwwn.cdc.gov/clia/regs/ nurses [online]. AHRQ Publication No. journal/123-1310/4018/content.pdf. toc.aspx. 08-0043. 2008 March [cited 2011 Sep 29]. 8. U.S. Centers for Disease Control and 15. U.S. Centers for Disease Control and Available from Internet: http://www.ncbi. Prevention. Infection prevention during Prevention. Subpart B: certificate of waiver. nlm.nih.gov/books/NBK2649/pdf/ blood glucose monitoring and insulin In: Clinical laboratory improvement ch34.pdf. Vol. 8, No. 4—December 2011 Pennsylvania Patient Safety Advisory Page 125 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 8, No. 4—December 2011. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. 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Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. 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