Diabetes Safety Checklist

The diabetes safety checklist contains questions to ask patients and actions to take (ideally at the beginning of each appointment).  Any safety topic could trump the patient’s primary agenda item or reason for referral. Please refer to your program’s policies and procedures for relevant and current procedures. 

Reviewing a safety checklist helps patient safety and educator comfort. We've all had clients that ask, "Can I tell you one more thing?" just before leaving, and learn it is a safety concern that should have been dealt with at the start of the appointment.  It also assists with rapport building as it expresses that educators care about their patients' safety needs. 

 Assessing safety items helps with:

  • Identification of safety concerns that patients may not volunteer 
  • Time-management of priorities in the appointment
  • Patient education on self-triage for safety at home

Psychosocial Emergency

Psychosocial: What to ask Psychosocial: What to do
What, if anything, is getting in the way of you taking care of your health? For some people it is finances, stress or depression - or review PHQ. Call Calgary Distress Centre 403-266-4357 if client verbalizes intent to act on suicidal thoughts. ​

Hypoglycemia  

Hypoglycemia: What to ask Hypo: What to do

Insulin dose error with too much rapid insulin:

  1. What is your name, address you are currently at, phone number and is someone there with you? 
  2. What is your blood sugar now? Do you have sugar or jam there? 
  3. How many units rapid do you usually give and how many did you actually give?
  4. How many grams of carbohydrate do you usually eat at this time or what do you usually eat for breakfast?
You can ask the patient to call PADIS (1-800-332-1414 Alberta) immediately; they will work through this with the patient  or the educator can follow their program's protocol for insulin dose errors which may include:
  1. Inform patient you may call 9-1-1 to have EMS assist if the patient becomes non-responsive or you cannot reach at a planned call. 
  2. Have the patient consume 1/4 cup sugar (60g carb) or less depending on blood sugar, age etc dissolved in water so you have time to ask the following questions and do math. 
  3. Do this math: (units of rapid insulin given ÷ usual rapid insulin dose)  X (usual grams CHO eaten at the meal) – 60 g = extra grams of CHO to eat.
  4. You may have to add up the grams of carbohydrate they usually eat if they don't carbohydate count.Each of the following is about 15 grams: 1 bread, 1/2 cup potato, 1 cup milk, 1 cup fruit, 2/3 cup juice, 1 tbsp sugar/regular jam.
  5. Instruct the patient to check blood sugars at least hourly for 6 hours. If unable to maintain readings over 4 mmol/L or to ingest adequate CHO due to nausea have the patient, caregiver or educator  call 911. Advise client NOT TO operate a car.

See your program's full policy or refer the patient to PADIS (Poisin and Drug Information Centre 1-800-332-1414 for Alberta)



  1. Have you had 3 or more readings a week less than 4.o mmol/L? (If elderly, less frequent)

  2. Have you had periods of sweating, shaky, dizziness, extreme hunger, sweating, bad dreams or or damp pillow when you wake?

What symptoms do you have if your blood sugar is < 4.0 mmol/L? If hypo-unaware review:
  1. Strict avoidance of hypoglycemia by considering ac targets 6.0-10.0 mmol/l for 1-3 months (or individualized).
  2. Driving guidelines handout
  3. Hypoglycemia Unawareness handout 
  4. Suggestion for referral to endocrinologist
  5. Consider if CGM is appropriate.
Have you had a low you could not treat by yourself?  Discuss use of glucagon in clients with type 1 diabetes and review glucagon handout. Investigate frequency, causes and preventative measures and assess for hypoglycemia unawareness. Chart “severe” hypoglycemia only if client was unable to treat episode by him/herself.
How do you treat your low blood sugars?

Review Hypoglycemia symptoms / treatment handout.
Treatment 15 g glucose, retest in 15 minutes, retreat if needed. Review appropriate carbohydrate choices for treatment and need to treat lows before eating meal.

If CGM indicates extended period of hypoglycemia requiring repeat treatments, advise test fingerstick blood glucose. Repeated treatments may not be needed and may result in hyperglycemia.  Some educators recommended fingerstick verification for all low CGM readings to rule out false lows. 

Hypo: if on CGM

  1. If you have dramatically decreased energy, lack of focus and your sensor shows your glucose level is fine, what do you do? 
  2. When you calibrate your CGM, how often do you input a CGM sensor reading instead of a fingerstick blood glucose reading? How often do you calibrate? (Dexcom/Medtronic)
  3. Do you "reset" sensors for longer use? 
  4. What is your "low" alert set at? 
  1. Advise fingerstick glucose test if symptoms don't match sensor reading. 
  2. Advise calibration per manufacturer’s guidelines using only fingerstick blood glucose and a verified accurate meter. People have experienced hypoglycemia because of incorrect or missed calibration. 
  3. Advise additional fingerstick testing if “resetting” the sensor for longer wear than intended by the manufacturer. Accuracy and safety concerns can arise.
  4. Set low alert at a reading above 4.0 mmol/L so action can be taken to prevent hypoglycemia.

Hyperglycemia (DKA, HHNS)

DKA/Hyper: What to ask DKA/Hyper: What to do
  1. Are your blood sugars mostly over 14 mmol/L or A1c over 12%?

  2. If you have type 1 diabetes, do you test for ketones if over 14.0 mmol/L?

  3. ​If you are on a pump, do you carry a safety kit with ketone strips, insulin and syringe?

DKA can result in death. Review appropriate handouts: 

Check ketones if over 14 mmol/L in type 1 (give1.5 X correction if over trace ketones in urine, or over 0.6 mmol/L ketones in blood). Adjust other insulins as appropriate. Assess for causes of hyperglycemia: insulin omission, illness, accident, “bad” insulin, injection technique, insulin pump related issues .

ADVISE EMERGENCY SERVICES IF:

DKA suspected: nausea, vomiting, abdominal pain, rapid deep labored breathing, confusion and dehydration (dry mouth, cracked lips, decreased skin turgor, dark urine). Contacting physician as required.

HHNS suspected: type 2 diabetes with blood sugars > 25.0 mmol/L and is physically unwell, dehydrated, hypotensive and confused with an altered state of consciousness as HHNS may be considered (hyperosmolar hyperglycemic non-ketotic state). This is extremely rare.
Are you on an SGLT-2 inhibitor? Regardless of blood glucose level, send to emergency if on SGLT-2 inhibitor with symptoms of DKA (nausea, vomiting, abdominal pain, rapid deep labored breathing, confusion,  dehydration e.g. dry mouth and cracked lips, decreased skin turgor, dark urine).
If on Insulin Pump:
  1. Do you give second correction by syringe if first correction doesn’t work and ALSO change infusion set?
  2. Do you carry a backup syringe in a safety kit?
  3. Do you have a plan for insulin replacement if pump fails?
  4. Do you have a copy of your current basal rates, ICR and ISF at home? 

Review and provide: 

  1. Prevention of diabetic ketoacidosis (DKA) in insulin pump therapy (AHS) handout
  2. Coming Off Pump handout
  3. Troubleshooting list for hyperglyemia in insulin pump webpage
  4. A copy of the client's pump settings

Summary of DKA prevention in pump therapy: 

  1. Carry safety kit (insulin no older than a month,  syringe, ketone strips, glucose, meter, strips even in on CGM.)
  2. Test for ketones if > 14.0 mmol/L
  3. Give 1.5 times correction dose using syringe if ketones present (> trace in urine, > 0.6 mmol/L blood) or ir first correction (no ketones) didn't work
  4. Change infusion set if ketones or if unsuccessful first correction and still over 14.0 mmol/L
  5. Retest in 2 hrs

Hyper: If on CGM:

  1. If you have increased thirst, tiredness and your sensor reading shows your glucose level is fine, what do you do? 
  2. When you calibrate your CGM, how often do you input a CGM sensor reading instead of a fingerstick blood glucose reading? How often do you calibrate? (Dexcom/Medtronic)
  3. Do you "reset" sensors for longer use? 
  4. What is your "high" alert set at? 
  1. Advise fingerstick glucose test if symptoms don't match sensor reading. 
  2. Advise calibration per manufacturer’s guidelines using only fingerstick blood glucose and a verified accurate meter. Inform patient that some people developed DKA as a result of repeatedly inputting sensor glucose readings for calibration.
  3. Advise additional fingerstick testing if “resetting” the sensor for longer wear than intended by the manufacturer. Accuracy and safety concerns may arise.
  4. Ask about settings and use of alerts/alarms to aid prevention of hyperglycemia. 

Pregnancy

 Pregnancy Planning: What to ask Pregnancy Planning: What to do
Are you planning pregnancy?  Refer to diabetes in pregnancy clinic for preconception care. Review importance of preconception glycemic control to reduce risk of fetal malformation or loss. Discuss with MD regarding any medications contraindicated in pregnancy that may need discontinuing. Advise daily folic acid for at least three months prior conception
Are you using birth control? Ask all women of child bearing years. 

Do not assume the patient is using reliable birth control.

Discuss importance of contraception: hyperglycemia in early pregnancy increases risk of stillbirth and fetal malformation and can worsen diabetes complications in the mother.

Discuss role of metformin and insulin sensitizers in increasing fertility. Emphasize importance of adequate contraception.

Discuss lixisenatide (Adlyxine or Soliqua: lantus + lixisenatide) interfering with absorption of oral contraceptive agent (OCA). The patient must take OCA AT LEAST one hour before the lixi or 11 hours after.

Pregnancy: What to ask Pregnancy: What to do
Are you pregnant or could you be pregnanct? Ask all women of child bearing years. 

Do not assume the patient will tell you she is pregnant. Ask about last menstrual period.

If pregnant, refer the patient to a Diabetes in Pregnancy Clinic.

If pregnant, discuss with the MD an order to discontinue the following: (Refer to Diabetes Centre Calgary DIP document "Guidelines for discontinuing medications during pregnancy and preconception" or your program's procedures)

  • ACE or ARB
  • DPP-4 inhibitors
  • GLP-1 agonists
  • Lantus (MD dependent)
  • SGLT-2 inhibitors
  • Secretagogues
  • Statin
  • TZD

Advise start 1 mg folic acid daily.

Blood Pressure in Pregnancy:

  • Have you had any elevated BP readings at OB appointments? Do you have any swelling to feet and/or legs?
  • Have you had any of the following symptoms: headaches; blurred vision; nausea and vomiting; feeling of general malaise “heartburn” or pain in your right upperquadrant? (symptoms of HELLP)
Check BP according to Diabetes Centre Calgary protocol
  • If BP is 140/90-160/100, call patient’s OB.
  • If BP >160/100, send client to L&D for assessment.
Symptoms could be indicative of HELLP syndrome (Hemolysis,Elevated Liver Enzymes, Low Platelet count). Inform physician. 

Hypoglycemia in pregnancy:

  • See notes to the right as well as section above on hypoglycemia
If decreasing insulin requirements in 3rd trimester are not explained by usual causes and/or decreased fetal movement, suspect placental insufficiency. Refer to Diabetes Centre Calgary DIP Policy on ‘Decreasing insulin requirements'.

Hyperglycemia in pregnancy:

  • See notes to the right as well as section above on hyperglycemia.
  • If sugars remain elevated for >4 hours with appropriate correction and/or patient has nausea and vomiting and can’t keep food down, patient should go to Labor & Delivery unit or Emerg for assessment.
  • DKA could occur at glucose levels lower than 14.0 mmol/L in pregnancy. 
  • Inform client that DKA is associated with fetal loss.
  • Inform clients on insulin pump that infusion set changes will likely be needed daily in the third trimester.

Obstetrical concerns:

  • Are you feeling the baby move? (as instructed by delivering doctor or endocrinologist)
  • Could you be in labor? (Are you having contractions; has your water broke;do you have loose stools, backache or just "don't feel right"?)
  • After 28 weeks, the patient should feel at least 6 movements in 2 hours. If any concerns refer the patient to Labour and Delivery unit at your site. 
  • Refer client to Labor & Delivery unit if labor is suspected

Signs of Vascular Events

Vascular Safety: What to ask Vascular Safety: What to do
Have you had trouble speaking;  understanding; seeing; walking; sudden numbness; sudden weakness of face, arm or leg; dizziness; loss of balance; sudden severe unexplained headaches or any other unusual symptoms especially when blood sugars were not less than 4 mmol/L?

Assist client in seeking emergency care if symptoms currently present. If no current symptoms, advise client discuss with MD. Communicate with MD. Discuss risk of stroke and MI and  advise to seek urgent care if symptoms return.  (Investigate if hypoglycemia is the cause of any symptoms.) 

Foot Wounds

Foot Wounds: What to ask Foot Wounds: What to do
Do you have wounds or cuts to your feet or legs?
  1. If the answer to this question is, "No," consider booking a routine appointment for a foot assessment with yourself or other provider if not already completed. 
  2. If "Yes," assess for infection and other critical elements. If present, refer to MD, urgent care, emergency or Wound Centre at Sheldon Chumir. present, refer to MD, urgent care, emergency or Wound Centre at Sheldon Chumir.

Related Safety Concerns

 Related Concerns: What to ask Related Concerns: What to do
Are triglycerides (TG) 6 mmol/L or greater?  If TG 15.0 mmol/L or greater advise urgent referral to endocrinologist. For TG > 6 counsel regarding risk for pancreatitis. Advise client seek emergency care if develops symptoms of pancreatitis (abdominal pain or nausea that is worse after eating, swollen or tender belly). Counsel to avoid alcohol, fatty foods and large carbohydrate portions including juice and regular pop. Refer to a dietitian. . 
Blood pressure: Is systolic blood pressure 200 or greater? Is diastolic blood pressure 130 or greater? Discuss plan with referring physician or family doctor, or send to urgent care/emergency.