Inpatient Use of Continuous Glucose Monitors: Insights From Pennsylvania Patient Safety Event Reports
Christine E. Sanchez, Myungsun Ro, Rebecca JonesIntroduction
Inpatient use of continuous glucose monitors (CGMs) has historically been prohibited. Increased outpatient use, critical needs during the COVID-19 pandemic, and growing interest in allowing use of CGMs to manage blood glucose levels for hospitalized patients have prompted consideration of allowing inpatient use of these devices to manage blood glucose levels.
Methods
We conducted a retrospective mixed-methods study using event reports submitted to the Pennsylvania Patient Safety Reporting System (PA-PSRS) from 2022 to 2025 to identify inpatient safety events in which the presence or use of a CGM could have influenced the risk of patient harm. Structured and narrative data were coded and analyzed to characterize variables related to CGM use and assess the potential impact of CGMs on patient safety.
Results
We identified and analyzed 165 reports from 51 hospitals. More than 70% of reports described events in which the presence or use of a CGM increased the risk of patient harm (CGM risk events), while the remaining reports described a reduced risk (CGM mitigation events). Among CGM risk events, the most frequent issues were off-policy blood glucose monitoring (23.9%), missing CGM-related documentation (17.1%), malfunctioned and/or expired CGM (15.4%), unauthorized insulin administration (13.7%), and failure to remove or cover CGM (9.4%). Patients’ desire to use their personal CGM appeared across several CGM risk events, whereas transparent communication of glycemic information between patients and providers was commonly described in CGM mitigation events.
Conclusion
Data from this study showed that inpatient CGM use was associated with both increased and reduced risk of patient harm. Clear policies and consistent patient-provider communication may help to minimize these risks and enhance patient benefit.
Plain Language Summary
Many people with Type 1 or Type 2 diabetes use continuous glucose monitors (CGMs). These small wearable devices help track blood sugar levels throughout the day. Even though people commonly use continuous glucose monitors at home, hospitals have been slower to allow their use. This is due to uncertainty concerning their safety and accuracy in a clinical setting, versus the standard procedure of finger-stick blood testing several times a day. However, recent research, and the Food and Drug Administration’s temporary approval of in-hospital CGM use during the height of the COVID-19 pandemic, suggest that when used correctly, CGMs can be a reliable alternative to finger-stick tests, as well as offer additional benefits in monitoring and maintaining glucose levels of inpatients.
A recent review by Patient Safety Authority research scientists discovered that inpatient CGM use can be associated with both an increased and decreased risk of harm. Researchers found that when CGMs increased risk of harm, issues such as off-policy blood glucose monitoring, missing documentation, and unauthorized insulin administration occurred. However, the data representing a decreased risk of harm associated with CGM use highlights the potential for CGMs to be useful tools during a hospital stay. As CGM usage increases due to patient preferences and shifting hospital policies, facilities should consider the strategies outlined in this article and establish clear, consistent procedures and collaborative communication between patients and providers to foster safe, effective CGM use.