Tackling Insulin Safety using A Multifaceted, Multidisciplinary Regional approach


The Regional Insulin Safety and Knowledge project (RISK) aimed to identify and implement strategies to reduce insulin errors and improve the care of people with diabetes on insulin across North East England using a common approach to reduce errors linked to unfamiliarity with insulin charts and prescribing practices within each Trust. This included an educational poster highlighting a standard way of communicating insulin prescription, a regional inpatient insulin prescription chart, an insulin passport and patient information leaflet, and education package for hospital staff.


The National Patient Safety Agency received 3,881 wrong dose incident reports between August 2003 and August 2009. These included one death and one severe harm incident due to 10-fold dosing errors from abbreviating the word ‘unit’ (National Patient Safety Agency Rapid Response Report Safer Administration of Insulin NPSA/2010/RR013).

Additional evidence on insulin safety in hospitals began to emerge following the publication of results from the first National Diabetes Inpatient Audit where nationally 26 per cent of all inpatient charts had an insulin prescription error (NADIA 2010).

Original reporting of this information underpinned discussions across the North East Region regarding co-operative working to improve insulin safety under the auspices of the NESHA Safer Care programme and the Northern Region Diabetes Advisory Group.

Although the Safer Care North East Insulin Safety Group began work to remedy these issues, the group was not able to implement changes due to organisational changes following the publication of the White Paper Liberating the NHS. At this point a small group of interested clinicians developed a project plan to deliver work initiated by the original safer care group. This became the North East (NE) RISK group.

The RISK Project’s principle aim was to identify and implement strategies that would lessen insulin errors and improve the care of people with diabetes on insulin therapy. A regional perspective was adopted to capitalise on the good work that had already begun to achieve benefits from economies of scale, and to add strength to the work by creating an opportunity for a joint approach to service improvement.

Background considerations

Communicating insulin treatments between patient, carers and professionals has been identified as unsystematic and potentially unsafe for patients and therefore service improvement is required.

It was clear that the lack of consistency across the NE region regarding the format of inpatient insulin prescription and blood glucose charts was adding to the risk of inpatient insulin prescribing errors.

Following the National Patient Safety Agency Rapid Response Report in 2010 and subsequent Patient Safety Alert, The Adult Patient’s Passport to Safer Use of Insulin, there was a requirement that all people requiring insulin therapy received an insulin passport to provide information across healthcare sectors and act as a safety check for the correct prescribing, dispensing and administration of insulin.

There was a need to standardise insulin safety and education training/education for hospital-based professionals and this provided an opportunity communicate consistent messages and would mean that staff would have the same basic training irrespective of hospital base.

The project started in July 2011 and the final board meeting of this stage was in April 2012.


Project objectives included having in place practical tools that would improve the safety of insulin therapy, which would subsequently reduce the number of recorded insulin errors as measured by the National Inpatient Audit. An additional objective was to have teams from units across the region working together to achieve this common goal.

Of particular interest was the care transition when patients move from one area of care to another, for example from one ward to another or from hospital to the community setting.

  • Applying the Six Sigma methodology to look at care for people requiring insulin therapy where there is a transition across organisational boundaries. Identifying and prioritising areas of concern and developing an improvement solution to address these.
  • Standardise insulin prescribing across the North East region (e-prescribing/paper), in a hospital setting
  • Agree a regional approach to distributing the national insulin passport to maximise efficiency/engagement/distribution and resource within the region. (This objective was adapted due to changes in NPSA documents. It began life as: Evaluating the roll out of the National Insulin Passport across the North East Region.)
  • Develop a standardised training package for professionals involved in insulin prescribing and administration.

Success would be to deliver the objectives identified above and demonstrate different teams had worked together to achieve a common goal.  This work also needed to demonstrate that it could contribute to the benefits outlined in the project plan.

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QiC Diabetes Winner 2012
Best medicine management initiative
Tackling Insulin Safety using A Multifaceted, Multidisciplinary Regional approach
by NE Risk Group


Dr Nicky Leech

Job title:
Consultant Diabetologist
Place of work:
NE Risk Group


Quality In Care Diabetes

  • 2020 KEY DATES
  • Open for entry: Wednesday 18 March 2020
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  • Judging day: Thursday 10 September 2020
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