NPSA rapid response report on insulin safety

8th July 2010

The UK National Patient Safety Agency (NPSA) has issued a rapid response report aimed at reducing the number of wrong dose incidents involving insulin.
All organisations in the NHS and independent sector should ensure that (taken directly from source):
• All regular and single insulin (bolus) doses are measured and administered using an insulin syringe or commercial insulin pen device Intravenous syringes must never be used for insulin administration.
• The term 'units' is used in all contexts. Abbreviations, such as 'U' or 'IU', are never used.
• All clinical areas and community staff treating patients with insulin have adequate supplies of insulin syringes and subcutaneous needles, which staff can obtain at all times.
• An insulin syringe must always be used to measure and prepare insulin for an intravenous infusion. Insulin infusions are administered in 50mL intravenous syringes or larger infusion bags. Consideration should be given to the supply and use of ready to administer infusion products e.g. prefilled syringes of fast acting insulin 50units in 50mL sodium chloride 0.9%.
• A training programme should be put in place for all healthcare staff (including medical staff) expected to prescribe, prepare and administer insulin. An e-learning programme is available from: www.diabetes.nhs.uk/safe_use_of_insulin
• Policies and procedures for the preparation and administration of insulin and insulin infusions in clinical areas are reviewed to ensure compliance with the above.
Insulin safety forms part of the NPSA's 10 for 2010 improvement programme. The deadline for the above actions to be completed is 16 December 2010.

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