Project Information

Evaluation of Pharmacist Interventions to Prevent Hypoglycemia

Project Description: Pharmacists at UF Health Shands Hospital were provided with a scoring tool that identified patients at high risk for hypoglycemic events. Pharmacists were asked to review the scoring tool and the patients listed then document their actions in our electronic medical record EPIC. No additional training or guidance was provided; all interventions were left up to the individual pharmacist’s clinical judgement. Interventions could include notifying the primary team of hypoglycemia risk, modifying the patient’s diet, modifying diabetic regimen, modifying non-diabetic drugs with hypoglycemia risks, glucose monitoring change, or pharmacists could document no action necessary. After approximately one year of this scoring tool’s release, no impact on the incidence of hypoglycemia was observed. There are several potential reasons that pharmacist’s response to this scoring tool were unable to impact hypoglycemia event rates. Patients may potentially appear on the scoring tool after a hypoglycemia event has already occurred. Pharmacists may not look at the scoring tool until much later during their shifts, after which the primary team may have already made interventions or hypoglycemia events have already occurred. The purpose of this quality improvement project is to evaluate the timing and appropriateness of pharmacist interventions to prevent hypoglycemia in response to a scoring tool.

QPI: Stephanie, Molchan, (


Advisors: Carrie, Lagasse, (; Amy, Rosenberg, (; Benjamin, Staley, (

UF Health Big Aims: Zero Harm None

MeSH Keywords: Diabetes Mellitus, Hypoglycemia, Insulin, Pharmacists, Drug Monitoring, Drug-Related Side Effects and Adverse Reactions