Insulin safety – shared learning

1. Insulin safety – shared learning Presenter

2. Introduction – North DevonHow are we doing? National Diabetes Inpatient Audit – 2017 • Annual inpatient audit • Snapshot audit of diabetes in-patient care in England and Wales • Every hospital in covering diabetes in patient care • Overview of prevalence and care – 30+ measures

3. NHS Digital - National Diabetes Inpatient Audit

4. NHS Digital - National Diabetes Inpatient Audit • Point prevalence overview • Staffing (nursing / consultant / dietitian / podiatry / pharmacy) • Type of admission • Diabetes management (renal / footcare / blood glucose / infusions) • Harm from in-patient stay (medication errors) • Hypoglycaemic control • Patient experience • Staff knowledge • Overall satisfaction

5. NaDIA 2017 – North Devon District Hospital

6. NaDIA 2017 – North Devon District Hospital

7. NaDIA 2017 – North Devon District Hospital • Prevalence overview • Staffing (nursing / consultant / dietitian / podiatry / pharmacy) • Type of admission • Diabetes management (renal / footcare / blood glucose / infusions) • HARM FROM IN-PATIENT STAY (MEDICATION ERRORS) • Hypoglycaemic control • Patient experience • Staff knowledge • Overall satisfaction

8. NaDIA 2017 – North Devon District Hospital

9. NaDIA 2017 – North Devon District Hospital

10. NaDIA 2017 – North Devon District Hospital

11. NaDIA 2017 – North Devon District Hospital SO FAR SO GOOD!

12. NaDIA 2017 – North Devon District Hospital HOWEVER……… What happens when we don’t get things right?

13. Headlines!

14. Patient Safety Alerts issued by NHS Improvement Video link: https://youtu.be/sfKxQ1JwAWQ

15. Safety Alerts issued: By NDHCT Trust

16. Ensuring Accountability in the NHS: ‘NEVER EVENTS’ LIST 2018 • Medication: • Overdose of insulin due to abbreviations or incorrect device: • Overdose refers to when: • A patient is given a 10-fold or greater overdose of insulin because the words ‘unit’ or ‘international units’ are abbreviated; such an overdose was given in a care setting with an electronic prescribing system • A healthcare professional fails to use a specific insulin administration device – that is, an insulin syringe or pen is not used to measure the insulin • A healthcare professional withdraws insulin from an insulin pen or pen refill and then administers this using a syringe and needle

17. World Health Organisation Medication without harm global patient safety challenge

18. World Health Organisation Medication without harm global patient safety challenge • Launched March 2017 • Overall Goal: • Reduce the level of severe, avoidable harm related to medications by 50% over 5 years, globally • Early Priority Actions: • high-risk situations • polypharmacy • transitions of care

19. World Health Organisation Medication without harm global patient safety challenge • Launched March 2017 • Overall Goal: • Reduce the level of severe, avoidable harm related to medications by 50% over 5 years, globally • Early Priority Actions: • high-risk situations • polypharmacy • TRANSITIONS OF CARE

20. WHO Medication without harm global patient safety challenge – transfer of care • Insulin - ‘high risk’ medication • Transfer of care ‘high risk’ situations • 30 – 70% of medicines not correctly prescribed and administered following T of C • Admission and discharge • Learning from reported incidents

21. Review of NDHCT Incident Reports - 2018

22. Review of NDHCT Incident Reports - 2018 • 585 Medication incidents reported in total • 34 (6%) incidents involving insulin • 1 ‘medium harm’ (semi-permanent harm, loss or damage) • 9 ‘minor harm’ (short term harm, loss or damage) • 24 ‘no harm’ • 10 involving insulin issues on discharge • 1 ‘medium harm’ • 1 ‘minor harm’ • 8 ‘no harm’

23. Review of NDHCT Incident Reports - 2018 “Patient discharged from NDDH with no prescription. On discharge summary changed to regular insulin regime, GP contacted to write a new prescription, insulin administered by out of hours. Seen by regular nurses today and noted incorrect insulin prescribed.Patient sugar levels checked= BM-16.6mmol and patient feeling well.” “Post hospital discharge - nurse visited to administer insulin but no insulin sent home with patientCommunity prescription chart also differed to discharge summary. Prescription chart says twice daily insulin, discharge summary says once daily” “Visited this lady to administer her daily insulin due to her having Dementia. I went to open a new insulin vial, but it had expired. When I checked the details on the vial it had been dispensed from the chemist after it had expired.“ “Patient in residential home did not have more Insulin vials ordered, for DN to administer. Discussed with manager that this should have been ordered on repeat prescription.”

24. What actions were taken? “Blood sugars checked several times - nurse revisited to monitor whilst trying to source insulin; Discharge ward contacted to clarify how often patient has insulin and to see if Insulin left in the fridge on the ward; Devon Doctors contacted to generate a new script and to visit patient to rewrite community prescription chart; Health care assistant sent to multiple pharmacies to check for stock; Established Insulin is only once daily; Waiting for Insulin so that nurse can revisit to administer; Insulin now 5 hours overdue” “Informed GPInformed duty managerinformed day teamDatix completed” “Removed the insulin from the patient's house, and have reported it to the chemist. I will return it to the chemist so that they can investigate this further.” “informed Home Manager, informed “nurse“; rang GP surgery and ordered emergency vial to be collected today by staff”

25. In Summary • You are doing a great job! • Please continue to report incidents – to maintain our open and honest reporting culture • As insulin is a ‘high risk’ medication, accurate communication of information is vital • Admission and discharge remain ‘higher risk’ situations

26. In Summary • You are doing a great job! • The consequences of making an error when administering insulin are likely to be more serious than many other medicines • The consequences for the patient will be serious and more likely to result in hospital admission / readmission

27. Thank You for Listening Now over to you!5 mins plus 10 mins feedback

28. In your table groups: • Either using the incidents described in the presentation, or • Thinking of situations were we haven’t got things right (in relation to insulin) • What would you top 3 ideas / priories be, to improve services and patient care?