Pharmacy contribution to patient safety: Results of collaborative insulin baseline audit

Transcription

1 East & outh East England pecialist Pharmacy ervices East of England, London, outh Central & outh East Coast Pharmacy contribution to patient safety: Results of collaborative insulin baseline audit ummary and comment 54 NH trusts contributed to this audit of 1,602 patients on insulin therapy. Participation was voluntary and the organisations self-selected which wards to include. Approximately 6% of the total in-patient population reviewed were on insulin. 165 patients (10%) had missed or delayed doses of insulin; this included 37 reports of missed doses being due to omission of insulin from patients prescriptions and a few where insulin was prescribed but not available on the ward at the required time. Insulin has been identified by the NPA as a critical medicine where timeliness of administration is crucial and trusts are required to have taken steps to address this by February prescribing safety incidents were identified by ward pharmacy staff; the most common types were wrong/unclear administration device (50%), wrong/unclear dose or strength (23%), omitted from prescription (9%) and wrong/unclear product prescribed (8%). upply (48) and administration (75) incidents were reported less frequently. 92% (879) of the identified prescribing incidents were reported to have been resolved by pharmacy. The high risk nature of insulin therapy means that errors can potentially cause serious or life threatening adverse events. If only 1-2% of the pharmacy interventions prevent a severe adverse event, the patient benefit is obvious, and the data can be extrapolated to demonstrate the cost effectiveness of the service. More than half the wrong /unclear dose incidents included the use of abbreviations for the word unit and this was nearly always (98%) corrected by pharmacy staff. Use of such abbreviations can severely compromise patient safety and the NPA now requires that such abbreviations are never used. A number of trusts had no reports of abbreviation use which has implications for other organisations working to meet this requirement. election of insulin administration devices is a major issue and the dangers of incorrect selection are poorly understood. Whilst the increasing diversity of devices benefits patients self-administering insulin, there appear to be circumstances when it is problematic, particularly at care interfaces and for non-specialist clinicians. Only 14 safety incidents (1.3%) were reported in local safety systems and reporting of prescribing incidents appeared particularly low (0.7%). The audit has demonstrated the very high frequency with which pharmacy staff identify and resolve insulin related prescribing safety incidents and the very low frequency with which this activity is reported. Patients on insulin appear to be at particularly high risk of prescribing incidents and this requires consideration in terms of prioritising pharmacy services for this patient group and developing additional robust safety strategies for times when ward pharmacy services are not available. Acknowledgement: This work would not have been possible without the help and support of all the Trusts involved; the clinical pharmacy team is immensely grateful to all who took part and shared their data

2 Introduction The potential for insulin to cause major patient harm when used in error is well recognised; in the United tates, errors are reported more frequently with insulin than any other high-alert medicine 1. In England and Wales, the National Patient afety Agency (NPA) receives a large number of incident reports concerning unsafe use of insulin, including wrong dose, wrong product and insulin omitted 2. These three errors account for 64% of the 2000 patient safety incidents involving insulin reported to the NPA each year 3. Treatment with insulin is also a notable cause of hospital admissions, frequently due to hypoglycaemia. However, hypoglycaemia is also common in diabetic patients treated with insulin during inpatient stays. The 2009 NH diabetes inpatient audit found that patients with an identified prescription error had a higher number of hyper and hypoglycaemic episodes than those with no identified errors 4. Prescribing error rates have recently been reported in a large study in North-West England, with a mean error rate of 8.9 errors per 100 medicines prescribed 5. Most errors were made on admission to hospital and almost all were intercepted by pharmacists before they could affect patients. Doctors were found to rely heavily on pharmacists and nurses to correct errors. Pharmacists have a professional requirement to ensure the use of medicines is safe and clinically appropriate, but since many interventions which prevent patient harm are not reported, the current contribution made by pharmacy staff to the safe use of insulin is unclear. Patient safety incident reports capture only a small proportion of errors and reporting rates vary enormously between organisations 2. The routine incident reporting system may be poor at identifying patient safety incidents, particularly those resulting in patient harm 6. Thus, insulin errors reported to the NPA may not give a full picture of current safety issues. Prior to this audit, the NPA issued an alert Reducing harm from omitted and delayed medicines in hospital. Insulin was identified as one medicine where delay or omission could cause serious harm and trusts are required to have systems in place to address this by February The alert also requires annual audit of omitted and delayed critical medicines, so the audit reported here included baseline insulin data which would support this. It was also known that the NPA was planning further work on insulin in 2010, so participation would enable trusts to review insulin safety prior to any further NPA publication. Objectives To audit the frequency and type of insulin related patient safety incidents identified and resolved by pharmacy staff in acute, mental health and provider trusts across 4 trategic Health Authorities. To quantify the proportion of these incidents reported to the NPA. To raise awareness of safety issues with use of insulins and support local implementation of the NPA alert on omitted and delayed medicines, and future insulin safety initiatives. Results of collaborative insulin baseline audit-aug2010-v4-cl p2 of 11

3 Methods Data collection forms were developed by the of the East and outh East England pecialist Pharmacy ervices with subsequent pilot and review in 3 care settings; acute, mental health and primary care provider bedded units. The audit included a short background questionnaire (to collect general information about procedures and policies for insulin use at each trust) and data collection forms on all patients prescribed insulin for ward and dispensary use. Data were collected on any unintended or unexpected incident involving insulin which could have or did lead to patient harm. Incidents were coded as prescribing, supply or administration with further sub-codes adapted from those used by the NPA. A free text description of each incident was also included. Data were collected by pharmacy staff (pharmacists, pre-registration students and technicians) and drug charts were also reviewed to identify any unintended missed or delayed doses of insulin. For this baseline investigation explicit insulin audit standards were not set prior to data collection. However, accepted normal practice would require that patients receiving insulin prior to admission have the same insulin product/form prescribed unless contraindicated and that the insulin dose, route and frequency is legible, unabbreviated and complies with any local guideline. Data were collected in the last 2 weeks of April To enable participation by various organisations and to capture a broad range of interventions, the audit could be conducted on any number of wards for 1-5 days. Organisations within the geography were invited to participate via presentations and e mail and then self-selected which wards to include in the audit. Results 54 Trusts participated in the audit: 41 Acute Trusts, 8 Primary Care/Community Provider Units and 5 Mental Health Trusts 1602 patients on insulin were identified: 1517 Acute Trusts, 34 Primary Care/Community Provider Units and 51 Mental Health Trusts More than 26,000 patients were included in the audit, so approximately 6% of the total in-patient population reviewed were on insulin. However, since organisations were less likely to report patient numbers when there were no patients on insulin, this figure must be interpreted with caution. a) Omitted or delayed doses 165 patients had unexplained missed or delayed doses (10%) Mental Health patients appeared to have a slightly higher incidence of missed doses (23%) but this is likely to be due to extended periods of stay and low patient numbers (12). A substantial amount of the audit data on missed doses was collected by retrospective review of patients drug charts so the details of what had happened were not always clear. However, there were 37 reports of missed doses where insulin had been omitted from the patient s prescription. at admission doctor stated insulin dose not known and delay in insulin prescription being written was more than 12 hours patient admitted on Mixtard 30, not prescribed on chart, 2 doses in 24 hours missed, patient had high blood sugars There were some instances where the drug chart had not been signed but clinical or other information indicated that insulin had actually been given. imilarly there were a few occasions where missed doses were probably intentional but not clearly documented. A few missed doses were reported to be due to insulin having been prescribed, but not available on the ward at the required time. Results of collaborative insulin baseline audit-aug2010-v4-cl p3 of 11

4 b) Ward data - Prescribing incidents and pharmacy interventions A total of 957 prescribing incidents were reported Table 1 Prescribing incidents involving insulin (n=1602 patients) Number of incidents Incident type Total Resolved by Incident Reported pharmacy within trust Omitted from prescription 82 (9%) 67 (81%) 2 Wrong/unclear product prescribed 69 (8%) 63 (91%) 2 Wrong/unclear dose or strength 204 (23%) 196 (96%) 0 Wrong frequency 5 (1%) 5 (100%) 0 Wrong route 14 (2%) 14 (100%) 0 Wrong/unclear administration device 437 (50%) 411 (94%) 1 Not prescribed according to local guideline 42 (5%) 36 (86%) 1 Other 104 (12%) 87 (84%) 1 Where insulin was omitted from the prescription, this was largely identified by medicines reconciliation (52%) or chart review (33%) and when identified by medicines reconciliation, omissions were nearly always resolved by pharmacy. Wrong or unclear insulin product was particularly seen with Humalog, Novomix/Novorapid and Mixtard insulins. Patient transferred from another ward, original chart correctly stated Humalog Mix 25. New chart stated Humalog Mix 30. Patient continued to self administer correct insulin. Wrong insulin..novomix 30 selected instead of Novorapid Prescribed as mixtard should have been mixtard 30 ; u instead of units Wrong or unclear dose or strength accounted for 23% of all the coded prescribing incidents, with more than half including use of an abbreviation for units such as u. Other incidents included unintended dose changes on transfer between wards, unclear hand writing (eg four mistaken for seven) and differences between doses prescribed and those actually used by patients. Administration devices were very frequently not included on prescriptions or wrongly selected and this accounted for half of the identified prescribing issues. This problem was again largely resolved by pharmacy (94%). Apidra had been prescribed for a patient newly diagnosed with diabetes but no device was prescribed only the drug name was prescribed - no device on chart Lantus endorsed penfill by pharmacist but olostar pen in locker. Patient states use white pre-filled pen ie Optiset! Wrong route prescribing errors were relatively rare eg im or oral instead of sc. Other prescribing errors included confusion when sc and iv infusions were prescribed together, and inappropriate timing of doses. Less than 1% of the identified prescribing incidents were reported via local systems to the NPA. liding scale and human mixtard 30 co-prescribed does not appear sliding scale being administered however doses omitted by nurses missing cannula Results of collaborative insulin baseline audit-aug2010-v4-cl p4 of 11

5 Novorapid written up after stopping sliding scale but not Levemir. Dr did not realise that Levemir was also an insulin Mixtard dose reduced and re-written but old dose not crossed off Wrong time Lantus prescribed on instead of am c) Ward data - upply and administration incidents 48 supply and 75 administration incident codes were reported Unlabelled insulins and devices were by far the most common supply incidents (56%) and there were further problems with expiry dates not being put on vials and also non-stock insulins remaining on wards after patients had been discharged. On a few occasions insulins were not supplied (eg not stocked by pharmacy) or not available on wards resulting in missed doses. Administration incident codes were frequently associated with missed doses (65%). Uncertainties were reported when patients were self-administering insulin and the regime used either differed from or was not recorded on the drug chart. 4 (5%) administration and 3 (6%) supply incidents were reported to the NPA. Humalog mix 25 was left by patients bedside and the patient uses Humalog. Identified by ward pharmacist during ward round, the patient did not use the insulin. The correct insulin had been supplied for this patient and was in fridge on ward d) Dispensary data 22 trusts (40%) collected dispensary data (207 insulin prescriptions were recorded) 47 incidents were identified with 46 reported to be resolved by pharmacy The main prescribing incidents were wrong/unclear administration device (35) and wrong/unclear dose including abbreviations (7). Dispensing of a wrong administration device was identified on 2 occasions (neither reached the patient) and incorrect labelling once. e) Insulin background and policies 45 trusts/sites provided background information about insulin policies and use One third of these organisations had a separate chart or section of the drug chart for prescribing sc insulin and two thirds had this for iv insulin infusions. Pre-printed stickers for insulin were in use or being developed at several trusts. Others were producing new pre-printed charts for C and IV insulin, but comment was also made about separate insulin charts sometimes being missed. 7 trusts had a trust policy specifically for prescribing, supplying and administering insulin. Of these, 2 included timeliness of administration in the policy and 1 included what to do if doses are missed or delayed. 35 trusts had a general policy for patient self-administration of medicines, 21 of these included competency assessment and 4 had specific information concerning insulin. Most trusts (30) used both ward stock and named patient supplies for intermediate and long acting insulins. Named patient only supplies were much more frequent in community and mental health settings, but 3 acute trusts reported only using this type of supply. However, in trusts using both supply routes, several commented that named patient supplies were usually issued and intermediate and long acting insulins were held as stock on selected wards only. Results of collaborative insulin baseline audit-aug2010-v4-cl p5 of 11

6 Regarding double checking of insulin doses by nursing staff before administration, slightly more than half did not require this for sc doses. However, only 6 did not require a double check before administering iv insulin. Pre-filled insulin syringes for infusion were already in use at 1 trust and 2 reported that they were planning to introduce pre-filled syringes. 19 trusts had current safety initiatives on insulin which included participation in the Think glucose initiative, safety bulletins, diabetes newsletters and insulin posters/charts. 7 trusts reported conducting audits of hypoglycaemia rates. The audits were conducted through Think glucose work, participation in the NH diabetes annual audit, and monitoring use of hypo boxes by diabetes nurse specialists. The range of insulins available on trust formularies for initiation of treatment was generally restricted but the extent of this was very varied, ranging from only 5 insulin products to a few trusts with all 26 insulins available. Most trusts did not limit which insulin administration devices were included in their formularies (28) but there were a significant minority (15) which did. Discussion This audit has demonstrated that pharmacy staff routinely identify and resolve a large number of safety incidents which, without such intervention, could potentially cause serious harm to many diabetic patients requiring insulin. Most of these incidents concern insulin prescribing, where the key issues were omission of insulin from prescriptions, product selection, device selection and clarity of dosage. Despite governmental recognition of this clinical contribution made by hospital pharmacists as far back as it is still a poorly recognised function in many organisations, a fact recently demonstrated in staff surveys conducted to support the clinical pharmacy redesign learning set programme currently offered by the P Clinical Pharmacy Team. Omitted and delayed doses Data collected included information on missed or delayed insulin doses (obtained largely by chart review) which would support implementation of the NPA rapid response report Reducing harm from omitted and delayed medicines in hospital 9. Our baseline figure of about 10% of patients experiencing missed doses could be used for future comparisons, as missed dose audits are now required on an annual basis. The number of missed doses varied considerably between trusts which may be of local interest, but small patient numbers from individual organisations limit the reliability of these data. A significant number of missed doses were linked to omission of insulin from prescriptions. Pharmacy-led medicines reconciliation, as advocated in the 2007 NICE/NPA afety olution, is intended to improve patient safety by reducing medication errors on admission to hospital. The recent P audit of medicines reconciliation found that omitted drugs made up 73% of all unintentional discrepancies in medicines prescribed on admission 10. Omission of insulin from prescriptions was reported here on a total of 82 occasions (5% of patients on insulin). The 2009 inpatient audit by NH diabetes also found that insulin was not written up for 6% of patients on insulin 4. Omission of insulin was most commonly identified during medicines reconciliation. This is an important finding as it demonstrates that errors of omission are not limited to medicines where omission is likely to have limited clinical significance. Insulin is a critical medicine where omission has potentially life threatening consequences and medicines reconciliation appears essential to safe care of diabetic patients. Another interesting issue concerned recording of insulin administration on drug charts (including situations where patients were self administering their medicines). On some occasions where drug charts had not been completed it was unclear whether the insulin dose or just the chart entry had been missed. Charts generally include a system for actively recording medicines not given, but poor Results of collaborative insulin baseline audit-aug2010-v4-cl p6 of 11

7 documentation, particularly in situations where large teams provide care, increases the risk of confusion and error. Prescribing incidents Previous studies of prescribing errors in hospital have reported general error rates of 7-8% 5, but the figures reported here tend to suggest the error rate for insulin prescribing is much higher. The 2009 inpatient audit by NH diabetes also found a much higher prescription error rate (34%) for patients with type 1 diabetes 4. (Directly comparable figures cannot be obtained from this audit as multiple prescribing incidents have been reported for individual prescriptions.) It seems likely that the complexity of insulin prescribing (eg multiple similar name products, the increasing range of administration devices, variable IV dosing) is reflected in the high number of prescribing incidents identified. Of particular concern is the continued widespread use of the abbreviation u when prescribing insulin doses. There have been many reports of u being misread as zero or other numbers resulting in over-dosage and occasional fatalities. Advice not to use abbreviations when prescribing insulin has been included in the BNF for many years, but the risk is clearly not recognised by many prescribers. The abbreviation u was nearly always corrected by pharmacy staff but this approach will not be sufficient to meet the NPA s insulin safety report which states that the term units is to be used in all contexts and abbreviations such as u never used 7. However, some trusts had no reports of abbreviation use which has implications for other organisations working to meet this requirement. Dosage incidents also included basic issues such as unclear writing. This remains a possible source of error while most trusts still use hand written drug charts rather than computerised records. Incidents of wrong or unclear insulin prescribed were also common, particularly with insulins where there are multiple products with similar names. Errors are known to result more commonly with medicines that have similar names or appearance, so it perhaps surprising that several insulin product ranges available in the UK have similar names which are easily mixed-up. This seems to be best addressed at national level by the MHRA and manufacturers taking steps to ensure that product names are carefully considered in order to minimise such errors. Potential selection errors might also be considered when insulins are chosen for inclusion in trusts formularies. By far the most common prescribing incident was a wrong or unclear administration device. Whilst this may seem to have limited clinical significance, there have been significant adverse events when devices have been used incorrectly or a wrong device has resulted in missed doses. ome insulins are available in a large number of different devices designed to meet the varying needs of patients self-administering insulin. However, there appear to be circumstances when this diversity is problematic, particularly at care interfaces and for non-specialist clinicians. The e learning programme from NH diabetes for staff prescribing insulin may help address this, but as problems occur so frequently this requires further investigation. Pharmacy interventions and potential adverse events Pharmacy resolution of the identified prescribing incidents was self-reported without external verification. However, incident descriptions provided some insight into the steps taken to ensure appropriate insulin use and many of the interventions appear relatively uncontroversial in terms of improved patient safety eg dose and device clarification. Despite known problems with estimating potential levels of harm, a simple rating for this was included in the data collection forms, but individual interpretation was inconsistent. Pharmacy staff resolved 92% of the insulin prescribing safety incidents confirming the essential nature of the service to safe patient care. Delivering this service in the most effective and costeffective way will be necessary to meet the NH Quality Innovation Productivity and Prevention agenda. The NICE/NPA Medicines Reconciliation solution included a systematic review of the cost- Results of collaborative insulin baseline audit-aug2010-v4-cl p7 of 11

8 effectiveness of interventions aimed at preventing medication errors at hospital admission 11. The review found that the cost of each pharmacist led medicines reconciliation was about 10, but, that by extrapolation from U data on the costs of adverse drug events, pharmacist-led medicines reconciliation was the most cost-effective intervention. The cost parameters generated for preventable adverse drug events are shown in table 2 below: Table 2 Cost parameters for preventable adverse drug events 11 Cost parameter Range Detected medication errors 0-6 ignificant (non-increased length of stay) preventable adverse drug events erious preventable adverse drug events 713-1,484 evere, life threatening, or fatal preventable 1,085-2,120 adverse drug events Using these values for the 1602 patients in this study, if all incidents had been determined by pharmacist-led medicines reconciliation then the approximate cost of the service would be 16,020. This value is almost certainly a significant over-estimate of service costs as many incidents were identified by other pharmacy processes (such as chart review) with less time requirement. Nevertheless, using these figures, if 7-15 interventions prevent a severe adverse event or prevent a serious event, the service costs are met. The high risk nature of insulin therapy means that most errors are potentially serious or life threatening. If only 1-2% of the pharmacy interventions prevent a severe adverse event, the patient benefit is obvious, and can be extrapolated to demonstrate the cost effectiveness of this pharmacy service. Background and policies This questionnaire was included in the audit to determine what polices and safety initiatives were already in place to support the safe use of insulin. As might be expected, there were clear distinctions between sc and iv administration, with separate drug charts and extra safety checks in place for iv usage in many organisations. Information about self-administration policies was included because there are widespread anecdotal reports of patients not being allowed to self administer their insulin in hospital resulting in poor diabetic control. Although most trusts had self-administration polices in place, the prescribing incidents suggested that recording of self administered insulin doses is somewhat confused with some poor communication between patients and health professionals. The NPA alert on critical omitted and delayed medicines requires a policy to be in place which includes timeliness and what to do if a medicine has been omitted or delayed 9. As yet such policies were only in place at 2 sites but this will be essential by Feb Just under half of the organisations reported having some current insulin specific safety initiatives such as in house safety bulletins and posters, as well as participation in national programmes such as Think glucose. Participation in the NH diabetes 2009 inpatient audit was only mentioned by a few trusts. If pharmacy departments are not aware of this activity it raises considerable concerns as one section of the audit covers prescription errors for diabetic patients managed on oral hypoglycaemic agents and/or insulin. Dispensary perspective Although only limited data were collected from pharmacy dispensaries, key prescribing problems were again device selection and dose clarity. The first of these means that dispensing is delayed as steps are taken to determine which product to supply, with the potential for delayed or missed doses. The second similarly causes delay and could result in a serious adverse event if the wrong dose is used. Both have major implications for safe care and costs (ie time spent by professionals resolving incidents or the costs associated with serious adverse events). Results of collaborative insulin baseline audit-aug2010-v4-cl p8 of 11

9 Reporting incidents to the NPA The NPA defines a patient safety incident as any unintended incident which could have or did lead to harm and the same definition was used for this audit. The Agency advocates reporting all incidents and all possible degrees of harm/severity. All NH organisations in England and Wales have been able to report patient safety incidents to the NPA via the National Reporting and Learning ystem (NRL) since 2005 and the Care Quality Commission now expects regular reporting to the NRL, on at least a monthly basis. In this study only 14 of the incidents identified were reported and the reporting of prescribing incidents appeared particularly low (<1%). Pharmacists have a professional requirement to ensure safe access to medicines and are required to be satisfied of the clinical appropriateness of medicines supplied to individual patients. As this audit has demonstrated, the number of incidents identified solely for insulin is very high, which might explain the reluctance to report all those that are potentially harmful. The low reporting rates across all 54 organisations clearly show that reporting issues are common to all. The types of prescribing incidents identified are broadly in line with NPA reports 3, but other approaches, such as this intensive audit or case reviews 6, may offer an important additional perspective. Limitations of audit findings NH trusts in East and outh East England volunteered to participate in the audit and chose which wards to include, so findings may not be representative of other areas. The study design also allowed trusts to collect data for 1-5 days with self-selection of the study timeframe. More than 94% of the patients included were from acute trusts; the small numbers from mental and community health settings limit the value of separate analysis by trust type, but some feedback on this will be provided to individual trusts that took part. Carina Livingstone August 2010 Results of collaborative insulin baseline audit-aug2010-v4-cl p9 of 11

10 References 1. Rashidee A et al. High alert medications: Error prevalence and severity. Patient afety and Quality Healthcare 2009;July/August: National Patient afety Agency. afety in doses: Improving the use of medicines in the NH. Learning from national reporting 2007 (published 2009) Cousins D. What do we know about the risk and harm associated with insulin? Pharm J 2010:284: Findings from the 2009 inpatient audit. NH Diabetes (personal communication) 5. Dornan T et al. An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education EQUIP study Baba-Akbari ari A et al. ensitivity of routine system for reporting patient safety incidents in an NH hospital: retrospective patient case note review. BMJ 2007;334:79 7. National Patient afety Agency. Rapid Response Report: afer administration of insulin. June Department of Health. The way forward for hospital pharmacy. HC 1988/54. London: The tationary Office; National Patient afety Agency. Rapid Response Report: Reducing harm from omitted and delayed medicines in hospital Dodds L. Results of a collaborative audit of Pharmacy-led Medicines Reconciliation (MR) in 56 trusts across E and E England. MR audit report 11. Campbell F et al. A systematic review of the effectiveness and cost-effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital admission. (Report commissioned by NICE as part of the Patient afety Pilot 2007.) APPENDIX - Participating organisations East of England Basildon and Thurrock University Hospitals NH Foundation Trust Bedford Hospital NH Trust Colchester Hospital University NH Foundation Trust East & North Hertfordshire NH Trust Hinchingbrooke Health Care NH Trust Ipswich Hospital NH Trust Luton & Dunstable Hospital NH Foundation Trust Mid Essex Hospital ervices NH Trust Norfolk & Norwich University Hospitals NH Foundation Trust Papworth Hospital NH Foundation Trust Peterborough & tamford Hospitals NH Foundation Trust Princess Alexandra Hospital NH Trust outhend University Hospital NH Foundation Trust uffolk Mental Health Partnership Trust West Hertfordshire Hospitals NH Trust West uffolk Hospital NH Trust Results of collaborative insulin baseline audit-aug2010-v4-cl p10 of 11

11 P London Barking, Havering & Redbridge University NH Trust Barts & The London NH Trust Central and North West London NH Foundation Trust Central London Community Healthcare Chelsea & Westminster NH Foundation Trust Epsom and t Helier University Hospitals NH Trust Hillingdon Hospital NH Trust Hounslow and Richmond Community Healthcare Imperial College Healthcare NH Trust Kingston Hospital NH Trust Moorfields Eye Hospital NH Foundation Trust Newham University Hospital NH Trust NH Lambeth North Middlesex University Hospital NH Trust North West London Hospitals NH Trust Royal Free Hampstead NH Trust outh London and Maudsley NH Foundation Trust outh London Healthcare NH Trust t George s Healthcare NH Trust Tower Hamlets Community Health ervices NH Trust University College London Hospitals NH Foundation Trust Whittington Hospital NH Trust outh Central Buckinghamshire Hospitals NH Trust Hampshire Community Health Care Milton Keynes General NH Trust NH Isle of Wight NH Milton Keynes Nuffield Orthopaedic Centre NH Trust Oxford Radcliffe Hospitals NH Trust Oxfordshire and Buckinghamshire NH Foundation Trust Portsmouth Hospitals NH Trust Winchester and Eastleigh Healthcare NH Trust outh East Coast Ashford and t Peter's Hospitals NH Trust Brighton and ussex University Hospital NH Trust East Kent Hospitals University Foundation Trust East ussex Community Health ervices Medway Community Healthcare Queen Victoria Hospital NH Foundation Trust Royal urrey County Hospital NH Foundation Trust ussex Partnership NH Foundation Trust Results of collaborative insulin baseline audit-aug2010-v4-cl p11 of 11