INS and Hyperglycemia: Examples included the following: a long length of stay in the ED with patient decompensation that required escalation of care; a patient with a dangerous level of hyperkalemia and severe hyperglycemia who received calcium, bicarbonate, and albuterol but did not have an insulin drip started before transferring to the ICU; and a pediatric emergency physician-ordered medication based on the body mass index instead of the patient’s weight, resulting in improper dosage.