ASHP 08: Insulin safety in transitions of care

According to Sandra Leal, PharmD, CDE, clinical pharmacysupervisor, El Rio Health Center, Tucson, and president, AmericanAssociation of Clinicians for the Underserved, also in Tucson,"We see patients who are leaving the ER and going to the pharmacyand then coming to us." She notes that many of these patientsdon't know how to self-manage their insulin and diabetes.

"Patients are bringing errors to our attention," said Dr. Leal."For example, we have patients who don't know what kind ofinsulin they are taking. Patients also share vials of insulin. Ilive an hour from the border, and patients go across to Mexicoand get meds.

"We need to [do a better job of helping patients to] self-manageand take their meds properly. Beyond insulin, our patients areusually on many meds. When we try to reconcile medications, it isdifficult for a number of reasons. Perhaps patients are afraid totake their insulin out of the refrigerator to show it to us. Wetell them it is important. Sometimes pharmacies will switchinsulins on the patients because of insurance or formularyissues. This can occur many times during a year."

Pharmacists also need to consider things beyond insulin, said Dr.Leal. "Patients will tell us, ‘my meter wasn't working, thebattery ran out.' They don't always see the seriousness of thesituation. We know that patient counseling is difficult; it ishard to make patients understand what they need to do and whythey need to do it.

"Patients will [check their blood glucose and take their insulin]when they feel like doing it. Elderly patients especially canhave difficulty with understanding. I repeat the instructions.Sometimes they leave with a functioning meter with 10 strips, andthen they can't afford the strips. So you need to ask, 'do youhave insurance, is this meter covered?'

"Also patients often don't know the goals of treatment," said Dr.Leal. "They don't know what they are testing for. An example: Ihad a patient who had high blood glucose readings; she was downto 150 and went to the ER thinking she was sick.

"Counseling is critical," she said. "You have to make surepatients can self-manage. The simplest intervention can have agreat impact." She suggested that pharmacists should make surethat patients have a glucose monitor that works and that patientsknow how the monitor functions (how to code it); pharmacistsshould also determine whether insurance covers the monitor.Pharmacists should check to see whether patients have a batteryand test strips for the monitor and should determine whetherpatients know what they are testing. Pharmacists should make surethat patients know how to self-manage hypoglycemia/hyperglycemiaand how to recognize the signs and symptoms of these conditions.Finally, pharmacists should see if patients have a medical homeother than the ER and should suggest classes or other resourcesthat are available at no charge to patients.