124 Diabetes Spectrum Volume 26, Number 2, 2013 Pharmacy and Therapeutics Insulin Use in Hospitalized Patients With Diabetes: Navigate With Care Cecilia C. Low Wang, MD, FACP, and Boris Draznin, MD, PhD “ A man walks into a bar . . .” These classic words introduce countless humorous situations. “ A man enters a hospital . . .” Unfortunately, these words intro- duce distinctly serious situations that occur at the rate of > 35 million per year across the United States. 1 These words introduce a story in people’s lives that all too often includes mistakes, misadventures, and even preventable deaths. The hospital is a dangerous place. Approximately one-third of all deaths in this country occur in hospitals. 2,3 On any given day, up to 30% of all hospitalized patients have diabetes, placing almost one-third of inpatients at greater risk for com- plications that may adversely affect their hospital stay. The majority of these hospitalized patients with diabetes are treated with insulin, a medication that occupies a promi- nent place on the list of high-alert medications of the Institute for Safe Medication Practices. 4 It is the leading medication implicated in adverse events requiring treatment in a hospital emergency department. 5 Moreover, insulin is responsible for more drug errors during acute hos- pital care than other commonly used hospital medications. 6 What is the best approach to using insulin in the hospital setting? What skills and knowledge must providers have to make the most effective use of insulin and yet mini- mize the danger of hypoglycemia? There are no simple answers for these questions. As depicted in Figure 1, a single hospitalization often involves mul- tiple transitions, each requiring a careful approach to insulin therapy. The transitions begin when patients enter the hospital. Patients may be admitted to a ward or to the intensive care unit (ICU), proceed directly to the operating room, or undergo vari- ous invasive procedures. Patients then move within the hospital among dif- ferent levels of care with overlapping or sequential interventions such as nothing-by-mouth (nil per os [NPO]) status, enteral or parenteral feeding, medications that may worsen glyce- mic control, and hemodialysis. The clinical course may be influenced by existing or newly developing clinical conditions such as renal or hepatic failure that change the metabolism of insulin. Finally, patients transi- tion back to an outpatient setting, either directly to their home or to an intermediate setting such as a reha- bilitation or skilled-nursing facility. Thus, distinct features of every hospitalization include 1 ) the fluid- ity of the clinical situation, with changes in clinical status and need for interventions; 2) difficulty predicting or planning for when an event will occur (e.g., imaging, surgery, cancellations, NPO status, or timing of meals); and 3) numer- ous opportunities for breakdowns in communication among teams and various care providers at all levels. We propose a framework in which to consider insulin therapy in the hospital setting, a basic paradigm for starting and managing insulin therapy, with special considerations for specific situations (Table 1). This brief review will focus on practical aspects of glycemic management of patients with diabetes outside of the ICU setting. It will not include inpatient management of hypergly- cemia in patients without diabetes or