In both 2012 and 2013, the National Inpatient Diabetes Audit (NaDIA) showed the Trust had higher numbers of medication, prescription, management and insulin errors than the national average. In response the Derby Insulin Safety Group (ISG) comprising a senior diabetes inpatient specialist nurse (DISN), a pharmacist, head of patient safety, quality and improvement and a consultant diabetologist was formed. The Group made change at multiple levels to improve the standards of all aspects of diabetes care in the hospitals.
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We used an innovative, multi-faceted approach to improve insulin safety and foot care, using existing resources efficiently and effectively to make the project sustainable and transferable.
The use of a multi-professional Insulin Safety Group (ISG) comprising clinicians, pharmacists and head of patient safety, quality and improvement from management is, to our knowledge, a unique concept and key to our success. Our regular meetings and close watch on errors and its analysis made us able to tailor the changes to the need of the hospital. While many use point-of-care testing to screen for extremes of glucose levels, few have used modifications in electronic prescribing to drive improvements in safety. We are unusual in introducing regular quality assurance in foot care and hypoglycaemia, and hyperglycaemia management safety issues as part of business as usual. Our method of educating staff placed an emphasis on building relationships, sharing success and therefore improving morale and motivation to continue to drive standards.
The ISG was set up in October 2014. The result was evident in the NADIA September 2015, with sustained improvements reported in 2016 NADIA as well, in addition to the decreased significant event reporting in the Trust. The initial step was to analyse the baseline data including NADIA, Datix reports and root cause analysis ( RCA) of the never event. The RCA identified several potential sources of error: prescribing, dispensing of insulin and its storage, transport of medicines when a patient moves wards, management errors in insulin administration and a lack of understanding about insulin pharmacokinetics. Therefore the main objectives were to reduce medication, prescription, insulin and management errors; to improve staff knowledge and foot checks for patients; and to prevent all serious and never events and to reduce all diabetes-related incidents while improving patient experience. We carried out several mini-projects, including:
- Optimisation of electronic prescribing
The introduction of Electronic Prescribing and Medicines Administration (EPMA) in 2012 helped reduce prescription errors from 33.9% ( NADIA 2012) to 14.9% ( NADIA 2013). To address its limitations and to make it more safe, we collaborated with pharmacy and the IT department and introduced the following changes:
- In EPMA, drop-down options especially for all short/rapid-acting insulins and biphasic insulin were restricted to those at mealtimes.
- Highlighted that the rapid/short-acting insulins should be given with meals. (Supplementary materials)
- Alerts on electronic prescribing triggered to prevent prescription of 100 units of insulin.
- Increased staff awareness and education.
One stop education for ‘Safe Use of Insulin’ was made an essential training for all nurses, and insulin safety education was delivered to all grades of junior doctors in different settings, including induction and their own teaching slots. Credit card-size information packages for insulin profiles, Flow chart for hyperglycaemia and hypoglycaemia management guidelines for doctors and nurses.
There were marked improvements in our NaDIA results in 2015 and 2016 compared with 2013. We reduced medication, prescription , insulin and management error and reduced the number of severe hypoglycaemia episodes. We increased the uptake of the foot risk assessment in all inpatients with diabetes. Our initiatives meant that in the space of less than 12 months we changed our performance from below national average in 2013 to above national average in 2015, sustaining our improvements in 2016. Implementation of ward assurance has improved awareness of the importance of foot checks and appropriate management of hypoglycaemia and hyperglycaemia among nursing staff and healthcare assistants.
Sustainability and Spread
This significant improvement in patient care has occurred with no additional cost to the Trust. The formation of a multidisciplinary inpatient group to facilitate change is an easily adaptable initiative for any hospital. The minor costs incurred for printing of the insulin profiles and credit card-sized information for newly joined nurses and junior doctors were incurred by the hospital. The time for all the professionals involved in this project was within their job plan. Further developments will require additional resources, particularly nurse specialist and consultant time: we have recently secured funding through the NHS England Transformation Bid to increase the DISN time and for some dedicated time for the consultant diabetologist to develop the project. We envisage focusing on length of stay as a result of continuing improvements in safety.
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