Patients to get ‘insulin passports’ to avoid dose errors

  • Date: 07 April 2011

INSULIN therapy patients are to receive an ‘insulin passport’ in a bid to reduce dose errors.

The National Patient Safety Agency (NPSA) wants Type 1 diabetics to be given the document, plus an information booklet, to help them take an active role in their treatment. The passport would note the patient’s current insulin products and enable a safety check for prescribing, dispensing and administration.

The NPSA’s latest safety alert also calls for hospital inpatients to self-administer insulin “where feasible and safe”. The agency said this should “reduce the harm associated with incorrectly timing insulin administration with food, and deaths and severe harm caused by errors of omission such as failure to provide basal insulin while ’nil by mouth’.”

The move follows a review of the National Reporting and Learning System (NRLS) between November 1, 2003 and November 1, 2009 which identified 16,600 incidents – including six deaths and 12 resulting in severe harm. Of these, 26 per cent were due to the wrong dose, strength or frequency and 20 per cent were due to omitted medicine. Patients being prescribed or dispensed the wrong insulin product accounted for 14 per cent of incidents. Reported incidents involved patients with type 1 or type 2 diabetes who were using insulin.

Dr Suzette Woodward, Director of Patient Safety, NPSA, said: "Medication incidents continue to be a leading cause of harm in healthcare. With insulin this can lead to serious harm or death. The Insulin Passport offers patients and healthcare professionals a simple tool to help reduce that risk."

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