Rowan Hillson Insulin Safety Award ‘best in class’ insulin prescription chart competition

Authors

  • Umesh Dashora Diabetes and Endocrine Centre, Conquest Hospital, Hastings, UK
  • Mike Sampson Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
  • Erwin Castro Diabetes and Endocrine Centre, Conquest Hospital, Hastings, UK
  • Debbie Stanisstreet Lister Hospital, Hertfordshire, UK
  • Rowan Hillson Former National Clinical Director for Diabetes, Department of Health, UK
  • On behalf of the Joint British Diabetes Societies for Inpatient Care

DOI:

https://doi.org/10.15277/bjdvd.2015.028

Abstract

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).

References

Health and Social Care Information Centre. National Diabetes Inpatient Audit 2013. Available at http://www.hscic.gov.uk/searchcatalogue?productid=14305 (accessed January 2015).

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

National Patient Safety Agency. Safer administration of insulin 2010. Available at http://www.nrls.npsa.nhs.uk/resources/?entryld45=130397 (accessed January 2015)

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)

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

Dineen M. Six Steps to Root Cause Analysis. Consequences Oxford 2002. Available at http://www.consequenceuk.com/six-steps-to-rca (accessed July 2015).

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

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

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)

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

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

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

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2015-09-01

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