Improve the prescription of insulin
Released on - 05/03/2010
Patient Safety First holds focus week to improve the prescription of insulin
On 8th March, 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.
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 that come in varying strengths and different devices that may look or sound alike and lead to the prescription of incorrect medications.
As a result, there are five key elements that trusts are being urged to check:
1. That the date of prescription is clearly written
2. The prescriber’s signature and contact details (e.g. BLEEP number) are included
3. That 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, i.e. cartridge, pen or vial is clearly written.
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.
Stephen Brown, Director of Pharmacy at the University Hospitals Bristol NHS Foundation Trust and Patient Safety First’s Intervention lead for High Risk Medications says: “There are a number of risk factors when prescribing insulin to patients. Basic changes can decrease these risks and improve patient safety. Patient Safety First has created the ‘insulin prescription bundle’ data collection tool to help trusts understand where they need to make these changes. There is online support in the form of the High Risk Meds ‘How-to guide’ to help.”
So far, the insulin prescription bundle has been piloted in three trusts across the country – York, Bradford and Bristol. Dr Donald Richardson, Consultant Physician at York NHS Hospitals Foundation Trust and Patient Safety First core team member says: “We piloted the ‘insulin prescription bundle’ data collection tool in our trust in early December 2009. After analysing our results, we found that we needed to improve our insulin prescribing particularly with respect to the form of dosage (mode of administration) and so we have started small cycle tests of change that might improve the safety of our insulin prescriptions. We have ongoing measurements that will help us determine whether we make improvements and I recommend other trusts take part in the focus week and use the ‘insulin prescription bundle’ data collection tool. It will help improve patient safety and reduce the amount of incidents that take place as a result of mis-read prescriptions.”
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 visit www.patientsafetyfirst.nhs.uk
