Summary

The Regional Insulin Safety and Knowledge project (RISK) aimed to identify and implement strategies to reduce insulin errors and improve the care of people with diabetes on insulin across North East England using a common approach to reduce errors linked to unfamiliarity with insulin charts and prescribing practices within each Trust. This included an educational poster highlighting a standard way of communicating insulin prescription, a regional inpatient insulin prescription chart, an insulin passport and patient information leaflet, and education package for hospital staff.

Results

Work stream 1 – Six Sigma

The work stream agreed and developed a unified way of communicating the important messages of correct insulin prescribing. This was distilled into a single poster, which was displayed in A&E departments, outpatient clinics and wards of one defined Foundation Trust.

The correct description for insulin was agreed as trade and generic name for single insulins. For combined insulin preparations, the percentage mix could be identified followed by the trade name, eg, 30/70 mix   Novomix 30; 25/75 mix HumaLog Mix 25; 50/50 mix HumaLog Mix 50 to reduce potential infusion with trade names for single insulins.

Audit data on the quality of insulin hospital discharge prescriptions was collected before and after displaying the posters.

This small-scale audit demonstrated that after the posters were displayed:

• 78 per cent insulin was prescribed correctly (42 per cent trade and generic and 36 per cent trade name for insulin mixes)
• There was an increase in correct prescription of insulin of 57 per cent
• 97 per cent of prescriptions had the dose stated – an improvement of 20 per cent, of these 51 per cent dose prescribed as words and figures.
• 98 per cent of prescriptions had a frequency specified - an increase of 15 per cent, of these 65 per cent prescribed according to recommendations.

Work stream 2 – Insulin chart

Over the five months of the project, representatives of diabetes teams (mainly the diabetes leads) for each foundation trust agreed the need for a common North East inpatient insulin prescription chart. For some Trusts this involved significant change in insulin prescribing practice. The key design elements for inpatient insulin charts are based on NPSA guidance. The chart was implemented from July 2012.

Work stream 3 – Insulin passport

This work stream agreed a regional approach to distributing the national insulin passport to maximise efficiency, engagement, distribution and resource within the NE region. It identified key people across the North East region involved in organising the distribution of the National Insulin Passport and reviewed the patient information leaflets available to be distributed with the passport. The group developed recommendations for providing the booklet and passport for patients and their carers for approval by the RISK board. The process for organising the passport and information is now underway.

Focus groups were planned to gauge user reactions to both the Insulin Passport and supporting Insulin Safety Leaflet. A number of groups were planned but, for varying reasons, only one took place highlighting the ongoing challenge of engaging patients using this methodology. The focus group provided feedback and a list of recommendations for both the insulin passport itself and the supporting patient information document.

Work stream 4 – Healthcare professional training

This group included diabetes consultants, diabetes educators, pharmacists and representative from a Trust education department. They designed a two-part training programme to be implemented as mandatory training to all healthcare professionals involved in insulin prescribing or administration in hospitals within the North East region.

NHS diabetes safer use of insulin online training was endorsed as the basic initial training across North East England. To deliver ongoing training, the team designed a 30-minute scripted, standardised training package, which can be accessed when the online package is completed, and delivered face-to-face to groups of healthcare professionals. An audit tool, to provide baseline data prior to the roll out of the North East insulin regional education programme, was used to measure effectiveness on a North East ward.

It is too soon to evaluate the impact of this work on patient outcomes and staff, as the numbers involved have been small to date. The plan is to use the National Inpatient Audit data in 2012 to see if there has been a reduction in insulin errors. Further evaluation will be based on local audits and measurement of interim outcomes such as numbers of people attending.

Challenge

The National Patient Safety Agency received 3,881 wrong dose incident reports between August 2003 and August 2009. These included one death and one severe harm incident due to 10-fold dosing errors from abbreviating the word ‘unit’ (National Patient Safety Agency Rapid Response Report Safer Administration of Insulin NPSA/2010/RR013).

Additional evidence on insulin safety in hospitals began to emerge following the publication of results from the first National Diabetes Inpatient Audit where nationally 26 per cent of all inpatient charts had an insulin prescription error (NADIA 2010).

Original reporting of this information underpinned discussions across the North East Region regarding co-operative working to improve insulin safety under the auspices of the NESHA Safer Care programme and the Northern Region Diabetes Advisory Group.

Although the Safer Care North East Insulin Safety Group began work to remedy these issues, the group was not able to implement changes due to organisational changes following the publication of the White Paper Liberating the NHS. At this point a small group of interested clinicians developed a project plan to deliver work initiated by the original safer care group. This became the North East (NE) RISK group.

The RISK Project’s principle aim was to identify and implement strategies that would lessen insulin errors and improve the care of people with diabetes on insulin therapy. A regional perspective was adopted to capitalise on the good work that had already begun to achieve benefits from economies of scale, and to add strength to the work by creating an opportunity for a joint approach to service improvement.

Background considerations

Communicating insulin treatments between patient, carers and professionals has been identified as unsystematic and potentially unsafe for patients and therefore service improvement is required.

It was clear that the lack of consistency across the NE region regarding the format of inpatient insulin prescription and blood glucose charts was adding to the risk of inpatient insulin prescribing errors.

Following the National Patient Safety Agency Rapid Response Report in 2010 and subsequent Patient Safety Alert, The Adult Patient’s Passport to Safer Use of Insulin, there was a requirement that all people requiring insulin therapy received an insulin passport to provide information across healthcare sectors and act as a safety check for the correct prescribing, dispensing and administration of insulin.

There was a need to standardise insulin safety and education training/education for hospital-based professionals and this provided an opportunity communicate consistent messages and would mean that staff would have the same basic training irrespective of hospital base.

The project started in July 2011 and the final board meeting of this stage was in April 2012.

Objectives

Project objectives included having in place practical tools that would improve the safety of insulin therapy, which would subsequently reduce the number of recorded insulin errors as measured by the National Inpatient Audit. An additional objective was to have teams from units across the region working together to achieve this common goal.

Of particular interest was the care transition when patients move from one area of care to another, for example from one ward to another or from hospital to the community setting.

• Applying the Six Sigma methodology to look at care for people requiring insulin therapy where there is a transition across organisational boundaries. Identifying and prioritising areas of concern and developing an improvement solution to address these.
• Standardise insulin prescribing across the North East region (e-prescribing/paper), in a hospital setting
• Agree a regional approach to distributing the national insulin passport to maximise efficiency/engagement/distribution and resource within the region. (This objective was adapted due to changes in NPSA documents. It began life as: Evaluating the roll out of the National Insulin Passport across the North East Region.)
• Develop a standardised training package for professionals involved in insulin prescribing and administration.

Success would be to deliver the objectives identified above and demonstrate different teams had worked together to achieve a common goal.  This work also needed to demonstrate that it could contribute to the benefits outlined in the project plan.

Solution

A project plan that included funding and support from NHS Diabetes, and three partners from industry, Lilly Pharmaceuticals, Novo Nordisk and Sanofi diabetes, was developed. Industry support was non promotional.  Further funding from Safer Care North East was given at a later date to support focus groups to take feedback from patients on the insulin passport.

The project plan was based on the original Safer Care work. It focused on four work streams with the aim of capitalising on the good work that had already evolved across the region, providing a forum for sharing outcomes and processes, and an opportunity to learn from each other.

A project manager (funded by the project) supported the four work streams and recruited members, organised meetings and recorded tasks. Members of the work streams were not funded. Each work stream had a designated lead, a set of deliverables and some tight timescales. Tasks were refined as the groups took shape. Work streams were specifically designed to include representation from each Foundation Trust in the NE and to be multidisciplinary.

A board, made up of work stream leads and other stakeholders, was tasked with monitoring the progress of the overall project and ultimately combining outputs of the individual work streams into a unified approach to insulin safety.

Key deliverables (Table 1)

As work progressed, the work stream focus began to merge, where projects had started out separately they developed natural partnerships and groups began to form in new ways to deliver outcomes. In particular, the chart and education work streams formed a close relationship where second level training would be based on the chart itself. At the Six Sigma workshop terminology for insulin prescribing, which also linked to the training work stream, was agreed and plans are in place to integrate this further.

The board set up a web page on the NHS Diabetes website to host updates which were also included in NHS Diabetes regional briefings and in a separate briefing sent out to teams. A letter was sent to chief executives outlining the project and encouraging their support and participation. A flyer outlining the project was developed for the Diabetes UK Professional Conference, March 2012 and this was circulated via network leads.

The approach was to use task and finish groups to focus on practical pieces of work that would build into a wider, more robust strategy to address insulin safety – the first part of the journey.

A letter has been written to the chief executives of all eight Foundation Trusts in the region, to be cascaded down through their Trusts outlining the work of the RISK group and seeking their support in implementing a new North East insulin chart, training package, safety surveillance and implementation of the standards on insulin communication.

Patient Representation

As these were essentially clinical groups, patients were not included as members. The regional manager from Diabetes UK was a board member as a proxy and patient input into the insulin passport and information booklet was achieved through the delivery of focus groups.

Table 1: Work streams and key deliverables

Learnings

The RISK project has demonstrated that if well co-ordinated and project managed, multidisciplinary collaboration across a region can achieve powerful consensus and a unified approach to the delivery of a multifaceted insulin safety programme.

At the outset the provision of a clear mandate and achievable deliverables along with a well-managed time line was important for achieving the outcomes in such a short space of time. Maintaining engagement with representatives of all Trusts and all stakeholder disciplines was key to achieving consensus on difficult issues such as the NE insulin chart and training package (where individual diabetes workers will have invested much time and energy into their own Trust’s approach). Allowing time for all representatives to debate the pros and cons of their current approaches and having forum for equal and open debate before reaching an agreement, was key.

One significant challenge was gaining consensus between those Trusts that prescribe insulin in hospital on a daily basis and those that prescribe once with re-prescription only with a change in dose. However, with commitment to the common goal of an electronic chart and innovation in chart design, an acceptable way forward was agreed.

The project manager was a vital part of the project’s success, demonstrating the importance of allocating time to deliver the organisational aspects of a project – making sure it is part of someone’s role rather than an add on.

The team was ambitious with its time line but was able to deliver – helped by maintaining focus and having very defined outcomes.

The RISK project is the beginning of ongoing collaboration between all diabetes teams in North East England to focus energy on a unified approach to insulin safety. The relationships and momentum that this has generated will, hopefully, provide a good foundation for continuing work.

Evaluation

The initial measures of success are against the key deliverables for each work stream (Table 1 above).

Six Sigma was successful in producing an education tool mapped to the identified risk areas in insulin communication. Through audit, it demonstrated a measured reduction in insulin prescribing errors and improvement in the quality and safety of insulin prescribing.

In work stream 2 (insulin charts), the successful thanks to the delivery of the NE insulin chart, which has been endorsed by all NE Foundation Trusts. Ongoing success will be measured through the regional ward insulin safety audit and through further data from the National Diabetes Inpatient Audit (NaDIA).

Work stream 3 (Insulin passport) delivered a successful regional strategy for the use of the insulin passport and information booklet. A single booklet, which will be printed and supplied locally, will be used across the region. It is national version 2 as approved by the NPSA. All insulin passports will be ordered by PCTs.  There is an agreed guideline for the process of distribution although this still has to be implemented.

Work stream 4 (healthcare professional training) was successful in standardising the approach to training and its acceptance by all Trusts. Ongoing success measures will come from feedback from each Trust education department regarding the numbers of staff who have certificates of completion of insulin safety training and ultimately the reduction in insulin associated errors as measured by ward audit tool and NaDIA.

The overall success of the NE RISK project can only be acknowledged if significant reduction in insulin associated errors is demonstrated and sustained across the NE region.