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National Patient Safety Agency

Passport to safer use of insulin

Wednesday 30 March 2011
The National Patient Safety Agency (NPSA) today issued a Patient Safety Alert, The adult patient’s passport to safer use of insulin, aimed at empowering patients with diabetes to take a more active role in their treatment to avoid being given the wrong insulin.


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




Notes to editors


1. Media enquiries to NPSA Press Office:


020 7927 9362 / press.office@npsa.nhs.uk


2. Errors due to incorrect use of non-insulin syringes and confusing insulin abbreviations have been the focus of previous guidance issued June 2010, see Safer administration of insulin (NPSA/2010/RRR013) at: www.nrls.npsa.nhs.uk/alerts


3. Patients under 18 years of age who have diabetes and use insulin are not within the scope of this Patient Safety Alert, although the use of the adult Insulin Passport and information booklet is an option available to them and their healthcare professionals.


4. Following the publication of the Arms Length Body Review on 26 July 2010, the NPSA has stressed the importance for all NHS organisations across England and Wales to continue reporting patient safety incidents through the National Reporting and Learning System (NRLS). This is so that trends in safety incidents can be identified and acted upon as early as possible.  This aspect of our work will continue within the new proposed structure of the NHS Commissioning Board and we will continue to work together in partnership with NHS organisations to make services even safer for patients.  We will continue to monitor the implementation of all patient safety alerts and guidance.