High-risk Pediatric Populations: Improving Safety and Reliability in Diabetes Care Management

High-risk Pediatric Populations: Improving Safety and Reliability in Diabetes Care Management

This is a patient safety alert about an immediate safety concern related to treatment of pediatric patients diagnosed with diabetes.

Resultant harm

More children are being diagnosed with diabetes. The ability to manage their care remains a challenge as the disease process can be complex and lead to other comorbidities. If symptoms of diabetes complications are not recognized early, the outcomes can be life-threatening.

Fundamental issue

Managing care for patients with diabetes can be a low-frequency, high-risk activity for health care providers who do not specialize in this patient population and do not have access to clinical job aides.

For example, patient harm can occur when:

Organizations lack:

  • Sufficient resources (e.g., clinical experts, job aides, policies/procedures/ protocols that align with the national standards) for each care setting
  • Appropriate patient monitoring systems (e.g., trigger mechanisms, active surveillance of hypo/hyperglycemia, glucagon use)
  • Adequate competency training for specific tasks/actions (e.g., use of diluted and concentrated insulin, reprogramming of insulin pumps)
  • Clear communication systems with the patient/family related to the care plan throughout the care continuum (e.g., inpatient, discharge)
  • Robust discharge processes (e.g., instructions, education) for patients/ families

Clinicians lack:

  • Knowledge of how and when to obtain expert consultation (e.g., endocrinologist, diabetes educator) or how to access internal resources throughout the care management process
  • Understanding of patient’s complete medical history and/or fails to validate medical information supplied by the family
  • Familiarity of national standards and internal resources available for the care management of patients with diabetes, which can lead to harm, such as missed recognition of serious disease complications (e.g., diabetic ketoacidosis), insufficient glucose monitoring, and medication errors

Recommendations to mitigate risk at your hospital

  • Conduct a risk assessment to determine organizational gaps related to improving the safety and reliability in diabetes care.
  • Use the provided Risk Assessment Tool developed by a team of your peers from children’s hospitals across the country.

Target audiences

  • Nursing, medical and clinical leaders, quality improvement, patient safety, legal/risk management, clinical educators, organizational leaders, primary care, emergency/urgent care, specialty care services, infection prevention and control.

What can I do with this alert?

  • Forward this alert to the recommended target audience for evaluation
  • Include in your Daily Safety Brief
  • Create loop-closing process for evaluating risks and strategies implemented to decrease risk of repeat harm
  • Let Child Health PSO® know what is working and what additional information you need
  • Leverage your PSO membership: Learn from each other to reduce patient harm and serious safety events

Has a patient experienced an event at your organization that could happen in another hospital?

  • Child Health PSO members should submit event details into the Child Health PSO portal.
  • Contact Child Health PSO Staff to share risks, issues to assess, and mitigation strategies with member hospitals.
  • More than 50 children’s hospitals are actively engaged with Child Health PSO. We currently are enrolling new members.

For additional resources, contributors and sources, download the PDF.


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About the PSO

The Child Health Patient Safety Organization enables children’s hospitals to share safety event information and experiences to accelerate the elimination of preventable harm.