Umesh Dashora,1 Mike Sampson,2 Erwin Castro,1 Debbie Stanisstreet,3 Rowan Hillson4 on behalf of the Joint British Diabetes Societies for Inpatient Care
1 Diabetes and Endocrine Centre, Conquest Hospital, Hastings, UK
2 Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
3 Lister Hospital, Hertfordshire, UK
4 Former National Clinical Director for Diabetes, Department of Health, UK
Address for correspondence: Dr Umesh Dashora
Consultant, Diabetes and Endocrinology,
Conquest Hospital, The Ridge,
St Leonards on Sea, TN7 7RD, UK.
Tel: +44 (0)1424 755255
E-mail: U.dashora@nhs.net
Br J Diabetes Vasc Dis 2015;15:135-138
http://dx.doi.org/10.15277/bjdvd.2015.028
The National Diabetes Inpatient Audit for 2013 described insulin-related prescription errors in over 21% of patients each year from the beginning of data collection in 2010. Error rates have fallen year on year but remain unacceptably high, with significant variation between hospitals. Many of these issues were related to insulin prescribing.
In 2014, the Joint British Diabetes Societies for Inpatient Care (JBDS) organised a competition for the ‘best in class’ current insulin prescription chart from hospitals in the UK. The aim was to identify safe and effective insulin charts, and make them available to the other clinical teams. A total of 41 Trusts submitted their insulin prescription charts, which were considered by an expert panel of independent judges against predefined criteria based on guidelines on the safe prescription of insulin from the UK National Patient Safety Agency.
The charts from Nottingham University Hospitals won this competition, with East Sussex Healthcare, Worcestershire Royal Hospital and Western Sussex Hospitals as runners up. The competition identified areas of particular strength in the winning charts, which are available online (see Box 1).
This article describes the background to the competition, with an account of the winning entry. The judging process highlighted a number of valuable mechanisms for improving insulin prescribing in UK hospitals.
Key words: Insulin, safety, prescription chart, award, competition
The National Diabetes Inpatient Audit (NaDIA) for 2013 found that about 16% of acute hospital beds in the UK were occupied by someone with diabetes,1 of whom 37% experienced at least one diabetes medication error, 22% at least one prescription error, 21% at least one insulin prescription error, and 22% at least one medication management error in their drug chart in the previous 7 days of admission. Inpatients whose drug chart had at least one medication error were twice as likely to have a hypoglycaemic episode compared to those whose drug chart had no errors. Alarmingly, 63 patients (0.4%) were reported to have developed diabetic ketoacidosis (DKA) after their admission to hospital. Higher rates of hypoglycaemia and DKA were thought to be linked to unsafe management of insulin. Most incidents of high or low blood glucose were due to failure to recognise trends in blood glucose levels and to alter the dose of insulin accordingly.
Problems with insulin safety are not new, with previous findings of risks to patients associated with absent prescription, displaced documentation, use of abbreviations in prescribing, and illegible handwriting.2 Between 2003 and 2009, the UK National Patient Safety Agency (NPSA) recorded more than 16,000 incidents involving insulin with 24% reporting harm to the patient and 18 with fatal or severe outcomes.3 The Department of Health included maladministration of insulin in its ‘never event list’.4 There is a clear need for innovative approaches to reduce errors in the prescribing of insulin in the UK.
In 2014, the Joint British Diabetes Societies for Inpatient Care (JBDS, a collaboration between the Association of British Clinical Diabetologists [ABCD], Diabetes UK, and the Diabetes Inpatient Specialist Nurse UK group [DISN UK]) launched an annual national competition for innovations to improve inpatient insulin safety. The JBDS group named this project after Dr Rowan Hillson, who was the UK National Clinical Director for Diabetes from 2008–2013. The JBDS Safer Insulin Prescribing group (authors UD, EC and DS) organised the best in class insulin prescription chart competition as part of the first of these competitions. This article describes the background to the competition, this year’s winner and important lessons for safer insulin prescribing that came out of the competition as a whole.
Noschese et al.5 described the following system barriers to effective prescribing of insulin, based on a review of charts with blood glucose values either >16.7 mmol/L or <2.2 mmol/L5:
1. Absence of a section on the chart for use of rapid acting analogue insulin
2. Absence of a very low dose scale for insulin-sensitive patients
3. Absence of readily-available guidelines for prescribing insulin
4. Lack of space for ordering scheduled insulin or for dose adjustments when nutritional intake changes
Other studies have indicated that poor knowledge and understanding of diabetes treatment is a potentially avoidable root cause of errors in the in-hospital management of people with diabetes.6
The solution lies in standardised prescribing guidance for the administration of insulin, which, compared with control patients, has achieved blood glucose within a target range with less risk of severe hypoglycaemia.6-9 One study found that standard charts led to less need for correction of insulin doses, with a trend to more appropriate orders.5,8 Such charts improved identification of insulin device, insulin administration, control of hypoglycaemia, compliance with evidence-based treatment, and opportunities to educate ward staff.10 This approach also improved the clarity of insulin orders, documentation, management of blood glucose levels and documentation.9 Standardised charts reduced prescription errors from 65% to 14%, and management errors from 40% to 14% from 2009–2012 at a hospital in Bournemouth, UK.11 In East Sussex, UK, the introduction of a chart reduced management errors from 25% to 6.5% in 4 years. There is a potential for a well-designed insulin drug chart to reduce insulin errors.
No single chart can be perfect with complete uptake and total elimination of errors.10 It appears that requiring a larger volume of information, for example blood glucose recording and timing of last meal, reduces the likelihood of any information being recorded.10 An attempt in Australia to mandate daily insulin prescribing after reviewing the blood glucose level reduced the incidence of hypoglycaemia but increased the incidence of hyperglycaemia, due to missed doses of insulin.9 Accordingly, the chart must be simple to use in order to reduce the risk to patients.
The NPSA and others have championed for many years the concept of a single, standardised national chart for insulin prescribing, without success so far. Varying needs, practices and existing protocols in different parts of the country mean that at present a common insulin chart is unlikely to be acceptable for every hospital. JBDS therefore conceived a national competition for the ‘best in class’ insulin prescription chart with the aim of promoting safer prescribing and allowing clinical teams access to the highest quality, and safest, insulin charts.
Diabetes specialist teams were invited to participate via the ABCD website and also by emailing DISN UK, which has members in 167 hospitals throughout the UK. The list was compiled by the administrator of the group who contacted individual hospitals and acquired details of DISNs who worked there. The invitation letter made clear that participants automatically consented to sharing their charts with other teams.
The quality of these charts was judged by an expert panel of independent judges (Appendix 1) according to predefined criteria based on the NPSA 2010 guidelines on safe prescription of insulin.3 These included aspects related to clarity, user-friendliness, coherence, logical order, safety, accuracy and presentation. These criteria were scored quantitatively as well as qualitatively by individual judges before a final decision was made by the chair (see Appendix 2).
A total of 41 Trusts (25% of all NHS Trusts with DISN in the UK) submitted their charts. Each Trust submitted eight copies of their insulin charts in use, which were centrally collected at the JBDS office, anonymised and sent to the judges. One winner, one runner-up and two highly commended charts were chosen. The results were announced on the occasion of a meeting of ABCD at the Royal College of Physicians, London, UK, on 6th November 2014. Robert Gregory (ABCD Chair) introduced the winners and Dr Rowan Hillson presented the awards.
The overall winner was Nottingham University Hospitals NHS Trust. East Sussex HealthCare NHS Trust entry was runner-up, with Worcestershire Royal Hospital NHS Trust and Western Sussex Hospitals NHS Foundation Trust awarded highly commended status. Jenny Clayton, Umesh Dashora, Erwin Castro, Joanne Shuck and Naomi Burns collected the awards for their respective organisations.
The charts can be accessed online, free to download and use by other Trusts who want to develop their charts or improve them at: http://www.diabetologists-abcd.org.uk/JBDS/insulin_ chart_winners.pdf (see Box 1).
An in-depth analysis of the comments made by judges on the various charts submitted, identified a number of themes which characterise a safe prescription chart (Table 1). Examples of comments made by judges about individual charts (unidentified here) are shown in Table 2.
The JBDS initiated the competition not only to recognise excellence in insulin safety, but also to share and disseminate safe practice throughout the country. Indeed, at least 41 hospitals have carefully designed their own insulin prescription chart to improve patient safety.
This insulin chart competition proved popular, and the winning charts are freely available to inspire other teams to improve their own charts, as described above. The great enthusiasm seen in this project mirrors the high level of uptake of similar charts, to the tune of 80%5 and 89%8 in previous studies. Previous qualitative research has highlighted the need to address the deficiency of useful information and poor communication for better management of insulin therapy.12 Any drug chart that seeks to improve insulin safety must contain all the critical information and guidance close to the place of prescription.
The judges’ remarks suggest that a rigid chart can occasionally create some difficulties. One should not forget that a drug chart is intended to support safe clinical decision-making, but not to replace it in every possible situation. There will be times where an unusual situation may demand a highly-specialised and individual prescription or monitoring in consultation with the specialist diabetes team. Care is needed not to introduce new problems such as over-complexity and excessive data entry leading to missed insulin doses.
Judges’ comments reflect that a safe chart should ideally be practical, appealing, user friendly, informative, educational and colour coded if necessary. Among other things (see above) it should include information on blood glucose monitoring, brand names, subcutaneous and intravenous prescribing, continuation of long-acting insulin, separate charts for separate situations, guidance for storage, preparation of variable intravenous insulin infusions and checking the dose before administering high doses. An ideal chart comprising of all these strengths is awaited. In the interim any trust can download the winning charts from the ABCD website (see above) and use them or improve them as per their needs.
We plan to run the Rowan Hillson Insulin Safety Award every year to identify, recognise and promote excellent practice for safer insulin prescribing that is already in routine use in the UK. Key areas identified relate to reduction of hypoglycaemia, mealtime insulin, monitoring, education and management of the diabetic foot.
Watch this space for further announcements about these competitions, as we continue to promote improved safety in the use of insulin.
Dr Rowan Hillson (Chair), Dr Clare Crowley, Consultant Medicines Safety Pharmacist (Oxford), Elizabeth Hackett (United Kingdom Clinical Pharmacy Association), Esther Walden, DISN UK Chair, David Gerrett (formerly NPSA), Bridget Turner (Diabetes UK), Dr Stuart Ritchie, Mags Bannister.
Space does not permit reproduction of the criteria for judging insulin charts here. These can be downloaded from: http://www.diabetologists-abcd.org.uk/JBDS/Criteria_for _judging_insulin_prescription_charts_2014.pdf
Acknowledgements Special thanks to Christine Jones for her administrative work and help with this project, and to the esteemed judges who evaluated the prescription charts.
Conflict of interest None.
Funding None.
1. Health and Social Care Information Centre. National Diabetes Inpatient Audit 2013. Available at http://www.hscic.gov.uk/searchcatalogue?productid=14305 (accessed January 2015).
2. Samarasekara RA, Sinton DT, Smith S. Failure, modes and effects analysis of insulin prescribing in Ninewells Hospital and Medical School Dundee. Improving prescribing theme SSC. University of Dundee Medical School 2005
3. National Patient Safety Agency. Safer administration of insulin 2010. Available at http://www.nrls.npsa.nhs.uk/resources/?entryld45=130397 (accessed January 2015)
4. Department of Health. The ‘never events’ list 2012/13. Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215206/dh_132352.pdf (accessed July 2015)
5. Noschese M, Donihi A, Curll M, et al. The effect of a diabetes order set on glycaemic management and control in the hospital. Qual Saf Health Care 2008;17:464-8. http://dx.doi.org/10.1136/qshc.2006.021790
6. Dineen M. Six Steps to Root Cause Analysis. Consequences Oxford 2002. Available at http://www.consequenceuk.com/six-steps-to-rca (accessed July 2015).
7. Cheung NW, Cinnadaio N, O'Neill A, et al. Implementation of a dedicated hospital subcutaneous insulin prescription chart: effect on glycaemic control. Diabetes Res Clin Pract 2011;92:337-41. http://dx.doi.org/10.1016/j.diabres.2011.02.019
8. Doyle MA, Brez S, Sicoli S, et al. Using standardized insulin orders to improve patient safety in a tertiary care centre. Can J Diabetes 2014;38:118-25. http://dx.doi.org/10.1016/j.jcjd.2014.01.003
9. Australian Commission on Safety and Quality in Healthcare. National inpatient medication chart (subcutaneous insulin) 2015. http://www.safetyandquality.gov.au/our-work/medication-safety/medication-chart/national-subcutaneous-insulin-chart/(Accessed January 2015)
10. Rushmer R, Voigt D. MEASURE IT, IMPROVE IT: the Safer Patients Initiative and quality improvement in subcutaneous insulin therapy for hospital inpatients. Diabet Med 2008;25:960-7. http://dx.doi.org/10.1111/j.1464-5491.2008.02470.x
11. Hamilton P, Nation M, Penfold S, et al. Reducing insulin prescription errors in hospital: more stick than carrot? Practical Diabetes 2013;30:370-3. http://dx.doi.org/10.1002/pdi.1813
12. Rousseau MP, Beauchesne MF, Naud AS, et al. An interprofessional qualitative study of barriers and potential solutions for the safe use of insulin in the hospital setting. Can J Diabetes 2014;38:85-9. http://dx.doi.org/10.1016/j.jcjd.2014.01.013