Endocrine Abstracts

42 insulin related incidents were reported within our Trust in 2014. Subsequent Root Cause Analysis revealed numerous insulin errors, hyperglycemia mismanagement and highlighted significant deficits in diabetes knowledge amongst nursing staff. To address the above issues, new safety interventions were introduced and five key outcomes are:

1. A new stand-alone insulin prescription chart introduced May’15 has seen insulin incidents decrease from 60 (Apr’14 – May’15) to 37 (June’15 – Apr’16).

2. A new, abbreviated DKA protocol and DKA App launched Aug’15 has shown significant clinical benefits and crucially, helped earlier discharge by 3.2 days (audit of 40 patients (13 between May – July’15 and 27 between Aug’15 – Mar’16).

3. A mandatory new “6 steps to insulin safety online module” introduced for all junior doctors & nurses (Dec’15) - 91 staff have already completed the module. Our CCG has recently introduced this successful module for care home staff.

4. Daily Hypoglycemia email alerts and Precision (Abbott) web database introduced to specifically target & educate problem wards. A number of changes have been already made as a result.

5. Ulysses SAFEGUARD IT now reports all insulin incidents monthly which are discussed as part of Quality Improvement. A monthly junior doctor insulin/prescription error alert (Aug’15) now mandates all error discussions with Educational Supervisors helping them reflect/learn from mistakes (11 insulin incidents in Jan/Feb’16 vs 19 in Nov/Dec’15).

Thus, over a relatively short period of 1 year, we have shown that our simple, yet helpful, safety innovations can be very effectively applied to reduce diabetes errors, improve staff knowledge & satisfaction. Our approach can be easily replicated by any NHS Trust to improve overall safety in insulin and diabetes management.