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.
So far, the insulin prescription bundle has been piloted in three trusts across the country – York, Bradford and Bristol.
Stephen Brown, director of pharmacy at University Hospitals Bristol NHS Foundation Trust and Patient Safety First’s intervention lead for high-risk medications, said: “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.”
Common confusions that lead to insulin errors in hospitals:
- 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.
Five key elements that trusts are being urged to check:
- That the date of prescription is clearly written
- The prescriber’s signature and contact details (e.g. BLEEP number) are included.
- That both the word ‘insulin’ and the brand name are written in full.
- The word ‘units’ is written in full with no abbreviations.
- The form of dosage, i.e. cartridge, pen or vial is clearly written.