Administering high-strength insulin from a pen device in hospital
HSIB Legacy
Published
Medication
Checking
This patient safety investigation looks at administering insulin from a pen device in hospitals. In 2017 there were 260,000 people with diabetes in the UK who experienced a medication error.
4 observations
1 action
Safety Observations (4)
It may be beneficial for insulin training to be competency based and specific to the healthcare practitioner’s role, in line with the ‘Diabetes: getting it right first time’ national specialty report.
The intention of this safety observation is to ensure that the workforce has the necessary knowledge and skills to care for patients on insulin.
It may be beneficial if national work was undertaken to review the robustness of the strategies to prevent administration errors with high-strength insulin and update accordingly.
The intention of this safety observation is to ensure that the medication regulator becomes aware of when an unlicensed medication is being widely used.
It may be beneficial for systems to support regulators in identifying when large volumes of unlicensed medication are regularly being prescribed to patients. Regulators can then engage in dialogue with the manufacturer about applying for a UK product licence.
The intention of this safety observation is to ensure there is clarity and consistency in the role and competencies of the diabetes nurse specialist.
It may be beneficial to conduct work to standardise the role, qualifications, training and competency of diabetes nurse specialists, as recommended in the Diabetes UK Position Statement.
Safety Actions (1)
The British National Formulary has been updated to provide information to healthcare practitioners on Humulin R U-500 insulin.