Secondary Logo

Journal Logo

Think “SAFE”: Four crucial elements for diabetes education

Hughes, Lucille MSN/ED, RN, CDE

doi: 10.1097/

Many patients newly diagnosed with diabetes are overwhelmed by all they need to learn before discharge. Improve their learning experience by using the SAFE acronym: signs and symptoms, administration, finger-stick testing, and emergency numbers.

Lucille Hughes is director of diabetes services at St. Joseph Hospital in Bethpage, N.Y.

The author has disclosed that she has no financial relationships related to this article.



WHEN PATIENTS ARE discharged, it's often difficult to find the time to provide proper education before they leave your facility. Patients who are newly diagnosed with diabetes need to learn many new skills, including how to monitor their blood glucose levels and give themselves insulin injections if needed. Yet they're discharged in less time than ever, and patients often don't feel up to learning when they're feeling stressed, anxious, and wanting to go home. So how can you make sure your patients get proper diabetes education before discharge?

Focusing on four crucial elements of diabetes education will help you give patients the information they need to manage their diabetes when they're at home. This article describes how to use the SAFE acronym to improve your patients' learning experience.

Back to Top | Article Outline

The SAFE way

Using the acronym SAFE is an easy way to remember the four crucial elements of diabetes education patients need before discharge from an acute care facility. (See Play it “SAFE”.)

Before you begin your patient teaching, perform a learning needs assessment and an assessment of the patient's readiness to learn. Results of the learning needs assessment will tell you two things: what your patient already knows and what he or she needs to know. Assessing the patient's readiness to learn helps you gauge your patient's ability and desire to learn at this moment.1 Let's take a look at each one.

Learning needs assessment: Assess what your patient already knows. Even newly diagnosed patients may have some knowledge about their disease. Make sure this knowledge is current and applicable to their type of diabetes. Ask open-ended questions to assess your patient's learning needs, such as “How does having diabetes affect your life?” or “Tell me what medications are you taking for your diabetes, and how they work.” Observation is another important assessment tool.1 If a patient requires insulin but hasn't self-administered an insulin injection or performed finger-stick blood glucose (FSBG) monitoring, you've just identified two important learning needs for your patient that fall under the “A” and “F” of the acronym SAFE.

Patient's readiness to learn: At times, you may be ready to teach patients all the elements of SAFE but they're not ready to learn them. In this situation, you may have to prioritize which elements of the SAFE acronym you'll teach. For example, you may only teach the “A” and “E.” Ask questions to help you assess your patient's readiness to learn, such as “Would you like to learn some facts about your diabetes self-management that can keep you safe at home?” or “Are you interested in learning about the diabetes medicine you'll be taking at home?”1 If your patient truly isn't ready to learn, include additional diabetes education material in the discharge papers to be read at home.

Providing patients with a brightly colored folder just for their diabetes education material can be helpful. A colorful folder will make it easy for your patients to identify the diabetes information from the sea of papers they get at discharge. It may be quite some time before your patient is ready to read them, so make them stand out from the rest.

Another helpful hint for situations when patients just aren't ready to learn would be to teach a family member, spouse, child, parent, partner, or other caregiver. Ask patients if they're willing to give you permission to teach someone close to them about their diabetes treatment and ask the patient who they would like that person to be. Be mindful of confidentiality issues and make sure patients give you permission to discuss their care with someone other than themselves.

Back to Top | Article Outline

S: Signs and symptoms

“S” stands for the signs and symptoms of hypoglycemia and hyperglycemia as well as their proper management. If your patient is taking a sulfonylurea (such as glipizide), a meglitinide (such as repaglinide), or any kind of insulin, provide education about the signs and symptoms of hypoglycemia along with the recommended treatment options for a hypoglycemic episode (see Recognizing hypoglycemia).2

Encourage patients to carry both a blood glucose meter and appropriate treatment options at all times. Let them know about options that are safe and reliable (see Oral treatment options for hypoglycemia). Make sure they understand that during a hypoglycemic episode, treatment must be fast and appropriate.25

Teach patients that if they experience the signs and symptoms of hypoglycemia, they need to check their blood glucose levels to confirm. (You'll show them how to use a blood glucose monitor under “F”). If the blood glucose level is less than 70 mg/dL, advise them to follow the American Diabetes Association's “Rule of 15” (see Follow the rules).3,4 Tell patients that if they find themselves without a blood glucose meter but are experiencing the signs and symptoms of hypoglycemia, they should follow the Rule of 15 just to be safe.

Reinforce the importance of carrying a blood glucose monitor and treatment options at all times. Remind patients to stick to the guidelines and eat 15 or 30 g of carbohydrate depending on the blood glucose reading.

Hyperglycemia, although not considered an acute complication, is a major cause of complications associated with diabetes. Signs and symptoms include a high blood glucose level, frequent urination, and increased thirst (see Recognizing hyperglycemia). Remind patients to report these signs and symptoms to their healthcare provider.6

Exercise is often used to lower blood glucose levels. Advise patients to check their urine for ketones if the blood glucose level is above 240 mg/dL. If ketones are present, exercise should be avoided because ketones may make blood glucose levels go even higher. Advise patients to work with their healthcare providers to find the safest ways to lower blood glucose levels.6

Back to Top | Article Outline

A: Administration

“A” stands for administration of oral medications and/or insulin. Review your patients' prescribed medications. Provide printed materials to enhance the learning process and provide a reference when they're at home. Teach them the indication and action of each medication. Let your patients know which are best taken with meals and review possible adverse reactions, especially those that have the potential to cause hypoglycemia. Warn them not to stop taking them on their own if they experience adverse reactions. If adverse reactions are troublesome, they should contact their healthcare provider for instructions.

Insulin analogues can cause hypoglycemia if not taken with enough carbohydrate or if the patient skips a meal. Let patients know this before heading home and returning to their usual meal plan and lifestyle.2

Before instructing patients about insulin administration, ask the healthcare provider which delivery method will be prescribed for use at home. Have patients observe the insulin administration process from start to finish, following the specific manufacturer's guidelines if an insulin pen is prescribed.

After providing patients a few opportunities to observe, have them self-administer as you observe. This same process holds true if they're going to use insulin vials and syringes at home.

Back to Top | Article Outline


“F” stands for FSBG monitoring. Performing an accurate finger-stick test may be all you get to show your patients before discharge. Learning their personal target blood glucose levels, when to check them, and how to interpret the numbers can be too much information for some patients at discharge, but it's important for them to know. Encourage patients to learn at least the basics of doing a finger stick and the general principles involved in using a blood glucose monitor, especially because the monitors they use at home may not be the same ones used in the hospital.

Before patients are discharged, let them know what their target blood glucose levels are and at what levels they should call their healthcare provider.

Back to Top | Article Outline

E: Emergency numbers and education

“E” stands for emergency numbers to call and outpatient diabetes education. Make sure your patients have the phone number of their healthcare provider in case blood glucose levels get too high or too low. Encourage them to continue their education about FSBG monitoring at a local outpatient Diabetes Education Center. If you're not sure of one that's close to where a patient lives, contact the American Diabetes Association ( or the American Association of Diabetes Educators ( Instruct them on when to call 911.

Back to Top | Article Outline

In the SAFE zone

Encouraging your patients to continue their diabetes education is a lesson that will serve them long after discharge. Even if you don't have the time you'd like to spend for proper education, providing the crucial elements of SAFE helps ensure that your patients get the information they need to manage their diabetes at home.

Back to Top | Article Outline

Play it “SAFE”

SSigns and symptoms of hypoglycemia and hyperglycemia as well as management

AAdministration of oral hypoglycemic agents and/or insulin

FFinger-stick blood glucose monitoring

E Emergency numbers to call and outpatient diabetes education

Back to Top | Article Outline

Recognizing hypoglycemia

Signs and symptoms of hypoglycemia include:

  • fast heartbeat
  • confusion
  • shaking
  • sweating
  • weakness
  • headache
  • passing out
  • getting very sleepy
  • seizures.4
Back to Top | Article Outline

Recognizing hyperglycemia

Signs and symptoms of hyperglycemia include:

  • high blood glucose
  • high levels of sugar in the urine
  • frequent urination
  • increased thirst.

Signs and symptoms of ketoacidosis (very high blood glucose level that's life threatening and requires immediate treatment) include:

  • shortness of breath
  • breath that smells fruity
  • nausea and vomiting
  • very dry mouth.2
Back to Top | Article Outline

Follow the rules

Teach your patients to follow the American Diabetes Association's “Rule of 15” when their blood glucose level is low:

  • Eat or drink something with 15 g of carbohydrates.
  • Wait 15 minutes and recheck your blood glucose level.
  • If it's still too low, eat another 15 g of carbohydrates and recheck your blood glucose level after 15 minutes. Once your blood glucose level begins to move into your target range, you should start to feel better.
  • Some patients overtreat themselves when their blood glucose level is low because they treat the symptoms, not the blood glucose level. Even if you don't feel better instantly after eating 15 g of carbohydrates, stick with the Rule of 15. If you keep eating until you feel better, your blood glucose level may get too high too fast. Be patient and wait the full 15 minutes.3

Let patients taking acarbose or miglitol know that only pure glucose (dextrose), which is available in tablet or gel form, will raise their blood glucose level during a low blood glucose episode. Food and drinks won't raise the blood glucose level fast enough because these drugs slow the digestion of other carbohydrates.4

Back to Top | Article Outline

Oral treatment options for hypoglycemia

The following options contain 15 g of carbohydrates:

  • 4 oz (1/2 cup) of fruit juice
  • 4 oz (1/2 cup) of regular (not diet) soda
  • 8 oz (1 cup) of milk
  • 5 or 6 pieces of hard candy
  • 2 tablespoons of raisins
  • 4 teaspoons of sugar
  • 1 tablespoon of honey or corn syrup
  • 3 or 4 glucose tablets
  • 1 serving of glucose gel.4,7
Back to Top | Article Outline


1. Moghissi ES, Korytkowski MT, DeNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15(4): 353–369.
2. Cryer PE. Hypoglycemia in Diabetes: Pathology, Prevalence, and Prevention. Alexandria, VA: American Diabetes Association; 2011.
5. National Diabetes Information Clearinghouse. Hypoglycemia.
7. Burkhart JA. Training nurses to be teachers. J Contin Educ Nurs. 2008;39(11), 503–510.
© 2012 Lippincott Williams & Wilkins, Inc.