Your Resource for HQIC Highlights and Learning Opportunities | Dec. 2021
Glycemic Management
An adverse drug event (ADE) is an injury resulting from medical intervention related to a drug.1 ADEs are among the most preventable causes of death in hospitals, and ADEs involving hypoglycemic agents comprise 57 percent of all ADEs, making this the largest drug class contributing to ADE-related harms.2

Fifty percent of all medication errors involve insulin—including one-third of all that are fatal—and approximately one-fourth of all safety incidents involving insulin result in patient harm.3

Rates of emergency department (ED) visits and subsequent hospitalizations for insulin-related hypoglycemia and errors were highest in patients 80 years or older, so it is important that patients and families understand safe administration of insulin at home prior to discharge from the hospital setting.4
It Figures—Data and Performance
The rates in the table below show that HSAG HQIC ADEs related to diabetic agents have improved slightly (lower rates are better). Tools and resources can be found in The Flash section and, as always, you can reach out to or your HSAG HQIC quality advisor for further assistance.

Visit the HSAG HQIC Quality Improvement Innovation Portal (QIIP) to view your glycemic management data by selecting the “Measure Category” of “Adverse Drug Events” and “Measure of ADE Diabetic Agent.”
The Flash: Resources
Glycemic Management Roadmap to Success 
This roadmap assists hospital teams in developing a successful, multidisciplinary glycemic management plan. The roadmap promotes a coordinated and systematic approach to inpatient glycemic management with input from frontline staff, nursing leadership, diabetes educators, and hospitalists—as well as departments of endocrinology, pharmacy, dietary, quality management, risk management, clinical education, case management, and laboratory. Roadmap steps of glycemic management include science-driven prevention and treatment, promotion of safer care, effective communication and care coordination, patient and family engagement, and best practices within the community.
Hypoglycemic Event Analysis Tool (HEAT)
Use this downloadable form to document and assess a patient's hypoglycemic event, including dietary status, prescriptions, and various contributing factors.
Diabetes Zone Tool
This two-page tool for diabetic patients explains glucose levels, where they should be at, and when to recognize problems with hypoglycemia and hyperglycemia.
Critical Communication
COVID-19 Vaccine Guidance for Rural Hospitals
COVID-19 vaccination slows transmission of the virus, saves lives, and is instrumental to post-pandemic life, yet many have not been vaccinated despite eligibility and adequate supply.5,6 The Rural Vaccine Confidence Initiative may help with building COVID-19 vaccine confidence at your hospital and in your community.
Events and Education
HSAG HQIC Quality and Safety Series
The Quality and Safety Series is designed to assist your organization in its quality improvement (QI) journey, from planning and preparation to sustaining gains.

The series, scheduled through the end of the calendar year, takes place the 2nd Tuesday of the month. These 30-minute-or-less "quickinars" are bite-size learning presentations that review the key skills necessary for you to function in the QI role or for other staff members who are participating in a QI initiative. The quickinars are intended as a foundation for the novice or as a skills refresher for the expert.
Quality and Safety Series 10: Process Mapping
Tuesday, December 14, 2021, 2–2:30 p.m. ET
HSAG Opioid Stewardship Program
Join HSAG in an action-based quickinar series to provide tactics, strategies, and information needed for a successful opioid stewardship program.

The 11 opioid stewardship quickinars are short, 30-minute webinar presentations that began October 21 and run through May 2022.
Upcoming Topics:
Developing a Dashboard
Thursday, December 9, 2021, 1:30–2 p.m. ET
1 Kohn LT, Corrigan JM, Donaldson MS (Institute of Medicine). To err is human: building a safer health system. Washington DC: National Academy Press, 2000. 
2 Levinson, D. R., (November, 2010). Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries. Office of Inspector General.
3 Geller AI, Shehab N, Lovegrove MC, et al. National estimates of insulin-related hypoglycemia and errors leading to emergency department visits and hospitalizations. JAMA Intern Med. 2014;174(5):678–686.
4 American Medical Association (AMA). Stepsforward™. Medication Adherence. 
5 Gupta S, et al. (August, 2021). Vaccinations against COVID-19 may have averted up to 140,000 deaths in the United States. Health Affairs.
6 CDC. (October, 2021). Vaccinate with Confidence.
This material was prepared by Health Services Advisory Group (HSAG), a Hospital Quality Improvement Contractor (HQIC) under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services (HHS). Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS. Publication No XS-HQIC-XT-11222021-01