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Patient Safety First holds focus week to improve prescription of insulin

This week, Patient Safety First is launching an ‘insulin prescription bundle focus week’ to encourage NHS trusts to improve the clarity of insulin prescriptions and reduce errors caused by the prescription of high risk medications.

Patient Safety First has put together a simple ‘insulin prescription bundle’ data collection tool, which trusts can use to test the clarity of their insulin prescriptions. A ‘bundle' is a grouping of best practices that individually improve care but when applied together result in substantial improvement to patient safety.

Common confusions

Some of the most common confusions that lead to insulin errors in hospitals include:

  • Staff having difficulty reading the prescribed numerical dose due to the figures or an instruction not being written clearly enough. Use of trailing zeroes can also cause confusion that could lead to overdoses of 10x or even 100x.
  • Mixing up of the words ‘units’ and ‘mls’ when abbreviations such as ‘u’ or ‘iu’ are used.
  • Misreading the name of the insulin product on the chart or product item. There are many different types of insulin and different devices that may look or sound alike and lead to the prescription of incorrect medications.

Five key checks

As a result, there are five key elements that trusts are being urged to check that:

  1. the date of prescription is clearly written
  2. the prescriber’s signature and contact details are included
  3. both the word ‘insulin’ and the brand name are written in full
  4. the word ‘units’ is written in full with no abbreviations
  5. the form of dosage, ie cartridge, pen or vial, is clearly written. 

“Diabetes UK welcomes this action," said Zoe Harrison, Care Advisor at Diabetes UK.

"These simple steps will help eliminate misunderstandings that could have serious consequences. At least 10 per cent of people in hospital have diabetes. Although not all people with diabetes treat their condition with insulin, the potential health risks to thousands of people can be avoided with simple measures.

“Hospitals should ensure that specialist diabetes teams are available to assure competences of non-diabetes specialist staff and provide appropriate support to ensure that people with diabetes in hospital are able to access the high-quality care they should expect.”

The insulin prescription bundle focus week 

During the week, using the data collection tool available from the Patient Safety First website, trusts will be able to find out how and where they need to improve the clarity of insulin prescriptions. This will also raise awareness of the importance of writing prescriptions legibly and the need to reduce the risk of harm from high risk medications.

The insulin prescription bundle focus week is the third of four dedicated focus weeks that Patient Safety First is holding to help trusts eliminate avoidable death and harm to patients.   

For more information please visitwww.patientsafetyfirst.nhs.uk.

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