Making Insulin Treatment Safer (MITS) Through Reflective Case-based Discussions


This project supports newly qualified doctors, final-year medical students on a pre-prescribing programme, and other insulin-prescribing professionals, to examine their insulin prescribing for inpatients via case-based discussions (CBDs). The CBDs are facilitated by aMaking Insulin Treatment Safer(MITS) trained doctor, nurse, pharmacist or person with type 1 diabetes (patient advocate).The aims are to empower prescribers to:handle the inherent complexity and uncertainty of prescribing insulin; work well with different disciplines and levels of seniority; respect patients’ rights to be involved in their own care and consult other people and information.

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The core activity is a MITS reflective CBD. A prescriber spends, on average, 30 minutes, one-to-one with a facilitator who has been trained to conduct an empowering, reflective conversation. The facilitator may be a pharmacist, doctor, nurse, or patient advocate. The CBD ends with the prescriber verbalising what they have learned and making explicit, written commitments to appropriate future prescribing behaviour based on their reflections of the CBD. The SMAC2 reflective tool was developed as a way of learning based on best research evidence, theories of clinical uncertainty and error, and reflective education principles. SMAC2 stands for: ‘Situation’, ‘Myself’, ‘Act’, ‘Check’, and ‘Check again’. It also offers some ‘Top Tips’ for effective insulin prescribing. This approach helps prescribers develop situational awareness, which is a key professional skill, and learn reflectively from experience. A set of standard operating procedures (SOPs) guides the implementation of MITS. Facilitator training begins with a half-day group experience, either conducted face to face or virtually. The training pathway continues with observation, supervision and mentorship to help facilitators achieve capability and accreditation. CPD certificates are issued on completion of training and accreditation is awarded when the facilitator pathway is completed. All Trusts in Northern Ireland (NI) were involved in phase 1 of the MITS project, with two moving towards flagship status in MITS2. Implementation was led by the MITS team along with Trust-based MITS Champions, who supported facilitator training and organised reflective CBDs at a local level. The plan is for all five Trusts to move to full implementation.


The proof-of-concept includes: progressive adoption of MITS into all medical, nursing and pharmacist prescribing education programmes in NI; acceptance by front-line clinicians; advocacy from those who educate them; evidence that MITS promotes interprofessional learning and patient involvement; positive effects on the morale of prescribers and facilitators, plus support from senior regional policy leaders. Educational theory and evidence provide a strong argument that these will improve patient care, reduce harm, and shorten length of patient stay over years, rather than months. MITS education is potentially transferable to any drug; indeed, to any safety-critical situation. During MITS2, one-to-one MITS CBDs were conducted with 60 medical foundation trainees and 77 medical students. The MITS reflective toolkit was taught to 100 nurses from two universities undertaking nurse prescribing courses, 42 participants in the Pharmacy Foundation programme, 10 trained and four trainee hospital-based dentists and two dental nurses, plus many other clinicians from physiotherapy, podiatry, and primary healthcare. A total of 54 de-briefers learned to conduct reflective CBDs with clinicians. MITS is now included in the basic prescribing curricula of all NI health professionals. Furthermore, nine facilitators are patient advocates. One of the most important outputs is a toolkit including standard operating procedures, evaluation instruments, and other materials that enable educators to transfer MITS to other locations. These are held as PDF documents and are all covered by Creative Commons licences, which allow others to use and reproduce them, but not use modified versions of them under the MITS/SMAC2 brand without written permission. Others are encouraged to use the MITS toolkit and provide feedback about their experiences.In addition, awebsite was developed as a central resource and for access to information and contact details. A leaflet has been produced for wide dissemination, which summarises the actions taken over the previous three years. It introduces a rebranding from ‘MITS’ to ‘Act Wisely’, which was an outcome of the project feedback. In addition, a stakeholder event was held in collaboration with Diabetes UK NI, at which a BBC journalist who has Type 1 diabetes facilitated. All stakeholders were invited, half of whom were people with Type 1 and Type 2 diabetes. One outcome of the event was that people with diabetes gained an understanding of the pressures that foundation doctors experience in their early careers. On the other hand, the professionals who attended gained an objective view of the expertise of people living with diabetes.

Sustainability and Spread

MITS is a long-term intervention, which aims to change the prescribing culture and influence the quality of practice and patients’ experiences of care. A joint statement by UK regulators and education providers has recently made the policy context more supportive of reflective education, which adds credibility to this approach. Further funding is being sought to develop reflective CBDs, facilitated by service users and health professionals, for all 250 assistantship medical students in the Queen’s University final year cohort 2021, and to transfer to two other implementation sites in the UK. The sustainability of MITS has been reinforced by increasing the range of programmes within which it is implemented. It is embedded in the nurse and pharmacist prescribing curricula. It has been successfully piloted in the 2019-2020 undergraduate medical programme and there is a commitment for this to continue at scale, in future years. A generic equivalent of the intervention has been developed. Presentations, networking, and accolades have attracted interest from other parts of the UK, including the Severn Deanery, where it is currently being implemented. In addition, there have been expressions of interest in developing this project from Galway, Glasgow and London. The plan is to develop a UK-wide Act Wisely/MITS Collaborative.

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  • 2023 KEY DATES
  • Open for Entry:
    Thursday 27 April 2023
  • Entry Deadline:
    Friday 7 July 2023
  • Judging Day:
    Tuesday 8 September 2023
  • Awards Ceremony:
    Thursday 12 October 2023