The NPSA is asking NHS organisations in England and Wales to give all adult patients on insulin therapy an Insulin Passport to help improve accurate identification of their current insulin products. This will provide essential information across healthcare sectors and act as a safety check for the correct prescribing, dispensing and administration of insulin.
A patient information booklet is also provided, empowering patients and supporting safer insulin treatment.
The Patient Safety Alert also asks for systems to be in place enabling hospital inpatients to self-administer insulin (where feasible and safe). This should reduce the harm associated with incorrect timing of insulin administration with food. It may also reduce the harm caused by missed doses such as when patients are ‘nil by mouth’.
The Patient Safety Alert follows a review of 16,600 patient safety incidents involving insulin, reported to the National Reporting and Learning System (NRLS) over a six year period between 1 November 2003 and 1 November 2009. Six deaths and 12 incidents resulting in severe harm were reported. Of the 16,600 incidents, 26 per cent were due to the wrong insulin dose, strength or frequency and 20 per cent were due to omitted medicine. Patients being prescribed or dispensed the wrong insulin product accounted for 14 per cent of incidents.
Dr Suzette Woodward, Director of Patient Safety, NPSA, said:
"Medication incidents continue to be a leading cause of harm in healthcare. With insulin this can lead to serious harm or death. The Insulin Passport offers patients and healthcare professionals a simple tool to help reduce that risk."
The Patient Safety Alert, The adult patient’s passport to safer use of insulin, and supporting material is available from: www.nrls.npsa.nhs.uk/resources/type/alerts
http://www.npsa.nhs.uk/corporate/news/passport-to-safer-use-of-insulin/
Issues in this article may affect your organisation or your employees or colleagues. The Healthcare e-Academy has a course which is specific to the above issues: our Safe Use of Insulin course, created in collaboration with NHS Diabetes. This course is FREE. If you are interested in registering for this course, then please visit http://www.healthcareea.co.uk/nhsdiabetes or contact info@healthcareea.co.uk
