Errors in insulin administration are common and can cause harm and even death. An audit aimed to standardise insulin syringe storage and labelling to improve safety
Insulin is a life-saving medication but, if wrongly administered, it can cause death or severe harm. Errors in insulin administration are common, including the inappropriate use of intravenous syringes. We surveyed all clinical areas in our trust to identify types of syringes and needles available and how these were stored and distinguished from IV syringes. Based on these results, we developed recommendations to promote safety and good practice and are standardising insulin syringes throughout the trust.
Citation: Reid A (2012) Changing practice for safe insulin administration. Nursing Times [online]; 108: 10, 22-26.
Author: Anna Reid is diabetes nurse consultant, Guy’s and St Thomas’ Foundation Trust, London.
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Over the past 18 months, several factors have prompted closer examination of insulin administration. These include:
- A report from the National Patient Safety Agency (2010a) on errors in insulin administration that led to death or severe harm;
- New recommendations from the Forum for Injection Technique on best practice in injection technique, including using needle lengths of 8mm and less to reduce the risk of intramuscular injection (Hicks et al, 2011);
- The expansion of the Department of Health’s (2011) “never events” list to include the maladministration of insulin.
This article discusses how we gathered data through audit and developed recommendations to reduce the risk of inappropriate insulin administration.
Nationally, it is estimated that 15% of inpatients have diabetes (NHS Diabetes, 2011a), which means hospital nurses are likely to care for a patient with diabetes most working days. Diabetes is a complex condition, with a wide range of possible complications that lead to increased hospital admissions and longer stays. In 2009-10, people with diabetes in England had 160,000 more admissions than those without the condition of the same age, and experienced 570,000 extra bed days (NHS Diabetes, 2011b).
At Guy’s and St Thomas’ Foundation Trust, 17-22% of inpatients have diabetes, and, of these, 42% need insulin therapy. On some wards, such as cardiac care, 50% of patients have diabetes and, despite insulin being a common medication, anecdotally many health professionals report a lack of knowledge in its use and administration.
Nationally, errors in the administration of insulin by health professionals are regularly reported, with 3,881 wrong-dose insulin reports received by the NPSA over six years up to 2009 (NPSA, 2010b).
The NPSA’s (2010b) alert identified two common errors in insulin administration:
- The inappropriate use of non-insulin (intravenous) syringes, which are marked in ml and not in insulin units;
- The use of abbreviations such as “U” or “IU” for units: when abbreviations are added to the intended dose, the dose may be misread, for example, 10U may be read as 100.
The NPSA (2010b) reported that three deaths and 17 other incidents occurred between January 2005 and July 2009 where an IV syringe was improperly used in insulin administration.
The following points include some of the recommendations to highlight correct use and provision of insulin syringes to enable correct administration:
- All regular and single insulin (bolus) doses are measured and administered using an insulin syringe or commercial insulin pen device - IV syringes must never be used for insulin administration;
- All clinical areas and community staff treating patients with insulin should have adequate supplies of insulin syringes and subcutaneous needles, which staff can obtain at all times;
- An insulin syringe must always be used to measure and prepare insulin for an IV infusion (NPSA, 2010b).
As part of the NHS Institute for Innovation and Improvement’s ThinkGlucose campaign (tinyurl.com/NHS-think-glucose), the trust’s safety and quality improvement in diabetes group monitors any insulin incidents and develops guidance, and has introduced practical procedures such as “hypo treatment” kits. The group has run a campaign to stop any use of abbreviations in insulin prescribing such as “U” or “IU” including training for all junior doctors, ongoing education events for nurses and screensaver alerts on prescribing.
Following these and other interventions, an audit of insulin prescribing showed an improvement from 85% to 100% compliance to prescribing in units. An insulin administration drug chart to support correct prescribing has recently been developed and is being introduced across the trust.
We undertook this audit of insulin syringes and storage to identify existing practice, possible areas of risk and how we could support wards and departments in further improving insulin safety.
The audit aimed to:
- Assess the existing safe storage of insulin syringes;
- Assess the availability of recommended needle lengths;
- Identify areas of good practice and share success trust-wide to ensure patient safety;
- Ensure compliance with the NPSA (2010b) alert;
- Reduce the risk of needles of inappropriate length being used in insulin administration;
- Implement measures to remove any risk of the inappropriate use of non-insulin (IV) syringes.
An audit tool was developed that examined seven areas including storage, labelling and content, types of syringes available, needle size and the estimated risk of mis-selecting a 1ml IV syringe instead of an insulin syringe.
We discussed the proposal with the matrons, who agreed to support the audit in all 61 wards and departments identified to use insulin syringes.
The audit was carried out by matrons, sisters and staff working in their own wards and departments.
A total of 90% of targeted clinical areas returned the questionnaire (55/61). Three areas did not stock insulin and insulin syringes and were therefore excluded from data analysis, so 52 responses were analysed.
Clinical areas frequently had more than one syringe store: 96% (50/52) stored insulin syringes separately while 4% (2/52) had no separation between insulin and 1ml IV syringes.
Labelling and content
The majority (98%; 51/52) of respondents reported that storage was labelled to identify content; 90% (47/52) said the labelling included the descriptor “insulin”. One area reported that insulin and 1ml IV syringes were mixed together.
Insulin syringes and needle lengths
A variety of syringe and needle sizes was available within and across clinical areas, with 58% (30/52) using 50-unit syringes, 48% (25/52) 100-unit syringes and 8% (4/52) 30-unit syringes.
A question about the brands of syringes available received 51 (98%) responses; the majority (96%; 49/51) used BD insulin syringes, with the remaining 4% (2/51) using Vanish Point syringes.
Forty-five of the 52 (87%) reported on needle lengths available; 62% (28/45) had 8mm needles available and 38% (17/45) had longer lengths available (Fig 1).
There was a variety of packaging for insulin syringes within and across clinical areas.
The majority (90%; 47/52) had syringes available in individual sterile labelled packets; multiple packs were available
in six (11%) areas. Some packs were sealed, some were open and, in some areas, the syringes were loose. Of these, two areas had sealed multiple packs; 6% (3/52) had opened multiple packs and 11% (6/52) had loose .
Risk of mis-selection of syringes
The auditors were asked to assess the storage and labelling of insulin syringes and estimate in their professional opinion the risk of mis-selection of an IV syringe instead of a insulin syringe.
Fifty of the 52 (96%) responded to this question; of these, 78 % (39/50) estimated a low risk, 10% (5/50) a moderate risk and 12% (6/50) a significant risk of syringe mis-selection (Fig 2).
Nurses conducting the audit reported that the most of insulin syringes were stored separately from IV syringes and were labelled as insulin syringes. Despite this, 22% felt there was a moderate or significant risk of mis-selection of an IV syringe instead of an insulin syringe.
Most areas ordered syringes individually wrapped, with sterile packaging that identifies them as an insulin syringe. However, some areas were able to order syringes in packs of 10 which, if stored loose without packaging, makes identification less easy.
More than one third of areas had insulin syringes available with needles longer than 8mm, increasing the risk of administering insulin intramuscularly; this can lead to rapid absorption and hypoglycaemia.
Overall, the results indicate good practice in the majority of areas in terms of insulin syringe storage and labelling of storage areas.
However, insulin is a dangerous drug if used incorrectly, and simple changes can be implemented to reach 100% compliance and reduce the risk of selecting the wrong syringes.
The data from this audit has enabled the diabetes team to make recommendations (Box 1). It has informed the process for rationalising insulin syringes available from procurement to improve safety throughout the trust. We are recommending that only individually wrapped 50-unit insulin syringes be made available, so that the packaging identifies the syringe as an insulin syringe and therefore promotes correct selection.
The larger the bolus of insulin injected subcutaneously, the slower the insulin is absorbed. The recommendation to use 50-unit syringes aims to encourage nurses to consider whether they should give the dose in two injections to promote effective absorption and promote greater scrutiny of larger doses, reducing the risk of administering a poorly written prescription.
Insulin syringes are only produced with needles of 12.7mm and 8mm in length. The recommendation on using syringes with 8mm needles complies with recent guidance advising that there is no clinical need for longer needles in insulin administration and shorter needles reduce the risk of administering insulin intramuscularly in some patients (Hicks et al, 2011).
We are undertaking educational and promotional activities, such as screensaver alerts, to publicise the key recommendations, and have incorporated them into ongoing regular teaching events.
We plan to re-audit, once the procurement process to rationalise syringe availability is complete, to ensure 100% compliance with recommendations.
BOX 1. KEY TRUST-WIDE RECOMMENDATIONS FOR INSULIN SYRINGES
Standardise insulin syringe to:
- 50-unit insulin syringe
- In individual sterile pack
- Single manufacturer
Needle size - 8mm only
All storage spaces for insulin syringes should be labelled “insulin syringes only” and be distinctly separate from IV syringes
This audit showed good practice in the vast majority of areas in terms of insulin storage and labelling in clinical areas. Despite this, 22% of nurses felt there was scope for improvement to minimise the risk of wrongly selecting an IV syringe, and simple measures have been put in place to tackle this.
The results also highlighted that, although the majority of clinical areas used the recommended 8mm needle length, longer needles were available in 38% of areas, and syringes available in multipacks or loose making identification difficult in 11% of areas.
We have recommended standardising insulin syringes to improve consistent identification and insulin administration safety across the trust and this is being implemented.
- Wrongly administered insulin can cause death or severe harm
- Insulin must only be administered using an insulin syringe
- Nurses must be able to identify the differences between IV and insulin syringes
- Wards and departments must ensure that insulin syringes are labelled and stored clearly and are separate from IV syringes
- An audit of practice can raise awareness and lead to recommendations for safe insulin administration
Department of Health (2011) The ‘Never Events’ List for 2011/12. London: DH.
Hicks D et al (2011) The First UK Injection Technique Recommendations (2nd edn). www.trend-uk.org
National Patient Safety Agency (2010a) Rapid Response Report NPSA/2010/RRR013: Safer Administration of Insulin: Supporting Information.
National Patient Safety Agency (2010b) Rapid Response Report NPSA/2010/RRR013: Safer Administration of Insulin.
NHS Diabetes (2011a) National Diabetes Inpatient Audit (NaDIA) 2010.
NHS Diabetes (2011b) Inpatient Care for People with Diabetes: the Economic Case for Change. Marion Kerr, Insight Health Economics.