Insulin prescribing – a dangerous minefield.

Insulin is responsible for a significant number of prescribing errors within the NHS despite this being listed as a ‘never event’ in 2011/12. In fact, the national diabetes in patient audit suggests that errors occur in one third of hospital patients. In particular, this refers to patients suffering recurrent hypos, developing diabetic ketoacidosis and having periods of hyperglycaemia during their inpatient stay. Errors can be due to prescribing or medicines management, the former including the prescription of the wrong insulin. Given the increasing numbers of insulins on the market from different companies, many errors occur from using the wrong nomenclature or uncertainty between similar sounding but very different products such as Humalog and Humalog Mix 25. This mistake is not just limited to hospital prescribing but computerised prescribing in primary care is also a source of errors. Other examples of prescribing errors include the lack of evidence of insulin administration – again not just limited to hospitals but also an issue in care homes. Poor management examples include periods of hyperglycaemia – on both subcutaneous and intravenous insulin and severe hypoglycaemia which can go unrecognised. Furthermore, prescribing and management errors are often compounded by a poor understanding of the action profile of different insulins.

Reducing these errors and potential patient harm can be achieved by a variety of means. In hospitals, the use of specialist teams in reaching to the wards to review in patients with diabetes can serve both as a way of management but also to educate ward staff. However, this depends on hospitals being adequately staffed – the most recent national diabetes inpatient audit suggesting that this is not always the case. Training of non specialist staff is also important with a number of web based training programs available. However, whatever the method is used to reduce errors, the maxim for the safe use of insulin whatever the situation remains…right insulin, right patient, right time.

Dr Mark Freeman

March 2015