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National Patient Safety Agency

New insulin safety guidance issued to reduce wrong dosages

17 June 2010

The National Patient Safety Agency (NPSA) has today 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.

“It is given to thousands of patients each day and the majority of cases this procedure is safe. However, there is a real potential for serious harm if it is not administered and handled properly.
“Common causes of error with insulin are inaccurate dosing and administration, leading to too little circulating glucose (hypoglycaemia) or too much circulating glucose (hyperglycemia).  Higher than required doses of insulin can suddenly lead to hypoglycaemia which if left untreated can lead to confusion, clumsiness or fainting.  Severe cases can go on to cause seizures, coma or death.
“This guidance is essential as the effects of wrong dosage can lead to catastrophic consequences.”
Anna Morton, Director of NHS Diabetes, said: “NHS Diabetes is pleased to support today’s guidance from the NPSA 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. “

Dr Rowan Hillson MBE, National Clinical Director for Diabetes at the Department of Health, said: “Diabetes is a growing problem. Insulin is a life-saving drug that keeps people with diabetes well. It is really important that all health professionals who care for people with diabetes are aware of how to use insulin safely. I would encourage anyone working in this area to read the NPSA guidance carefully and ensure they complete the e-learning module on the NHS Diabetes website.”

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
There is also further supporting material available provided by the NPSA on the Patient Safety First website where users can participate in an on-line discussion about this issue - http://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/relatedprogrammes/medicationsafety/



Notes to editors:


1. Media enquiries to the NPSA Press Office:
Simon Morgan – 020 7927 9580 / simon.morgan@npsa.nhs.uk
Dominic Stevenson – 020 7927 9351 / dominic.stevenson@npsa.nhs.uk

Out of hours – 0788 411 5956


2. The National Patient Safety Agency (NPSA) is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. For more information visit: www.nrls.npsa.nhs.uk.

NHS Diabetes works to raise the quality of diabetes care in England by supporting and working with the healthcare community and people with diabetes. In partnership with people with diabetes, they help develop and support new guidelines, standards and systems designed to improve care for people, and then encourage the widespread implementation of these new initiatives. For more information contact Oliver Jelley at NHS Diabetes on 07766 990848 or oliver.jelley@diabetes.nhs.uk


3. Safer use of insulin is one of the initiatives which form part of the 10 for 2010 Improvement Programme supported by the NPSA to help the NHS reduce harm associated with 10 high risk areas of healthcare.