The National Patient Safety Agency (NPSA) has issued guidance for all NHS organisations across England and Wales aimed at reducing the number of wrong dose incidents involving insulin.
The Rapid Response Report, produced by the NPSA in conjunction with key stakeholders and NHS organisations across England and Wales, is as a response to 3,881 patient safety incidents reported between 2004 and 2009.
These included one death and one case of severe harm that occurred after clinicians misinterpreted the abbreviation of the term “unit”. A further three deaths and 17 other incidents occurred between January 2005 and July 2009 where an intravenous syringe was used to measure and administer insulin.
The Rapid Response Report asks NHS organisations to ensure that:
• All regular and single insulin (bolus) doses are measured and administered using an insulin syringe or commercial insulin pen device (never using intravenous syringes).
• The term “units” is used in all contexts.Abbreviations, such as “U” or “IU”, are never used.
• A training programme is in place for all healthcare staff that are expected to prescribe, prepare and administer insulin.
• All clinical areas and community staff treating patients with insulin have adequate supplies of insulin syringes and subcutaneous needles.
• NHS Diabetes has developed an e-learning training course on the safer use of insulin to help healthcare professionals implement today’s guidance.
• Insulin safety forms part of the NPSA’s 10 for 2010 improvement programme. This builds on the campaigns Patient Safety First in England and 1000 Lives in Wales and aims to reduce avoidable harm in 10 high risk clinical areas.
• Professor David Cousins, NPSA’s Head of Patient Safety for Medication and Medical Devices, said: “Insulin is a widely used medicine used to treat diabetes.
Anna Morton, Director of NHS Diabetes, said: “NHS Diabetes is pleased to support this guidance and we have launched an online training course for health professionals to support it. Our Safe Use of Insulin website also includes a vast amount of practical information and a number of true stories illustrating the dangers when insulin is used incorrectly. “
For more information about the safe administration of insulin, visit www.nrls.npsa.nhs.uk/alerts or visit the NHS Diabetes website – www.diabetes.nhs.uk/safe_use_of_insulin
