RISKRegional Insulin Safety and Knowledge

Project

A focused collaboration between the Foundation Trustsof the

North East of England

Over 3 million people in the UK have diabetes

The majority will use insulin during their lifetime

Errors involving insulin are common

Errors involving insulin are under-reported

Errors involving insulin are avoidable

Errors involving insulin cause harm

Errors involving insulin can kill

Diabetes affects 1 in 6 in-patients ….

Background….

Stakeholder engagement

Workstreams identified

Project Manager appointed

Workstream output agreed

£

Implementation…

RISK

Forthright poster impact on wards

Insulin prescription chart

• One chart

• One prescription standard

• One prescription method

• Training for users

• Audit of use

01/04/12 007

10

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20

NE super hospital

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Useful Guidance on the front of the chart

Insulin must be prescribed on the e-prescription or drug chart in addition to this insulin chart.

Discharge - a moment of risk

Lispro (Humalog)12

1210

Glargine (Lantus)

24

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Fab pharma

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Insulin prescription chart progress

• One chart

• One prescription standard

• One prescription method

• Self administration

• Training for users

• Audit of use

Eight FTs

Six Sigma

Standard dose

Clear “permissions”

Education package

NDIA in place

Professional Education package

• Standardised for region

• Include available resources

NHS Diabetes Suite of safety e-learning modules

• Insulin chart at core of training

• Six Sigma communication approach

Insulin Passport and Booklet

NHS organisations should ensure by 31 August 2012:

That adult patients on insulin therapy receive a patient

information booklet and an Insulin Passport to help provide

accurate identification of their current insulin products and

provide essential information across healthcare sectors.

Insulin Passport & Booklet

• Passport supplies• Agreed leaflet for region

– Content– Logos– Printing

• Focus groups Acceptability

Usefulness

• Informed roll out for deadline

RISK

• Final Board meeting and write up end April

• Recommendations to FTs and CCGs

• Implementation by August 2012

• On-going review via Diabetes Network

• On-going audit within NDIA

• Legacy………

RISK Project Team

NHS Diabetes

Gillian Johnson

Project Manager

Jan Finn

Workstream Leads

Jean Macleod; North Tees, Raz Nayar; Sunderland, Nicky Leech; Newcastle, Sue Robson; NorthTyneside.

Safer Care NE

Emma Nunez

Not forgetting……

All those in the workstreams and focus groups