Safe use of insulin in primary care: Collaborative baseline audit of insulin administration and documentation by community nurse teams

Transcription

1 East & outh East England pecialist Pharmacy ervices East of England, London, outh Central & outh East Coast Medicines Use and afety afe use of insulin in primary care: Collaborative baseline audit of insulin administration and documentation by community nurse teams ummary This audit of insulin administration and documentation was conducted in 19 NH Provider Trusts by community nurse teams at the end of patients were reported requiring insulin administration by community nurses. Comparisons of 14 trusts reporting at least 20 patients demonstrated significant variation in many aspects of practice and insulin use. The data can be used to benchmark local activity and to drive both safety and cost improvements. *Directions to administer medicines: 15.7% of directions had an abbreviation for the word units which is now a never event. 7.7% were not signed and dated by the prescriber. Medicine details (e.g. insulin name and dose) were transcribed onto medicines administration records by someone other than the prescriber for 69.2%. *Administration: All insulin administration was by community nurses. Pens or disposable devices were used for 52.9%. For 17.0% of patients, community nurses reported using an insulin device without any prior device-specific training. Community nurses prepared insulin for 13.4% of patients so that it could be administered either by patients themselves or by a carer. *Frequency: Overall, 51.1% of patients had insulin administered more than once a day. However, several individual trusts reported less than 40% of patients requiring insulin more than once a day; these trusts generally had a higher use of long-acting insulin analogues. If the trusts reported here could manage at least 60% of patients who only have insulin administered by community nurses on a once a day regimen, the total annual service costs could be reduced by about 210,000 or by more than 3.5 million across the UK. Recommendations 1) Urgent action is needed to identify and correct all insulin directions where the word unit is abbreviated or the dose is otherwise unclear. 2) When insulin is administered by community nursing teams the administration device should be an insulin syringe. The insulin should be available and prescribed as vials. upplies of insulin syringes must always be available to community nurse teams. 3) Patients requiring insulin administration more than once a day should be reviewed by the prescriber and community team. Change to a once daily regime should be considered wherever possible to reduce demand on the community team whilst maintaining appropriate glucose control and quality of life. 4) Organisations should develop policies which define the circumstances where advance preparation of insulin syringes might be necessary. Pre-prepared syringes are effectively unlicensed medicines, so should only be used when all other options have been exhausted. 5) Directions for community nursing teams to administer insulin should have a standard format which is easily recognised and does not require transcription. uch directions must include the full name of the insulin, the dose to be given (with no abbreviation for the word units ) and be signed and dated by the prescriber.

2 Medicines Use and afety 6) Medicines Management QoF points could be used to incentivise GPs to review insulin patients managed by community teams and ensure directions to administer insulin meet the required quality standards. Acknowledgement: This work was co-ordinated by the Medicines Use and afety Division of the East and outh East England pecialist Pharmacy ervice and we are immensely grateful to all who took part and shared their data pecialist Pharmacy ervices Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 2

3 Medicines Use and afety 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. Whilst the majority of incident reports are from hospitals, there have been fatalities with insulin use in primary care, including overdoses administered in error using standard syringes instead of insulin syringes 4. Administration of insulin is a significant area of activity for community nurse teams. Patients are unable to self-administer insulin for various reasons, including both physical and mental impairment. Community nurse teams administer insulin for such patients in their own homes or residential care homes, and may also undertake blood glucose testing and other nursing care. Occasionally patients may be able to self-administer insulin, but need help drawing up insulin into a syringe or manipulating other insulin administration devices. The Royal College of Nursing has produced guidance for community nurses on Advance preparation of insulin syringes for patients to administer at home, but recommends that this should be avoided if at all possible 5. The NPA issued a report on afer administration of insulin in June 2010 which healthcare providers were required to action by December 6. One of the requirements is that community staff treating patients with insulin have supplies of insulin syringes and subcutaneous needles, which staff can access at all times. A recent audit in bedded units indicated that the plethora of different insulin administration devices, designed to support patient self-administration, can also present significant challenges for health care staff that are not diabetes specialists and encounter certain devices infrequently 7. imilarly, the NPA reports a serious incident occurring where a community nurse had not received any training about a particular insulin device 4. The NPA insulin report also indicates that the term units must be used in all contexts; abbreviations (e.g. U ) should never used. However, in April 2010, an audit of 54 NH trusts found that abbreviations were used on 112 occasions, affecting 7% of patients on insulin 8. Anecdotal reports suggest use of abbreviations continues in community settings where directions to administer insulin are largely hand written. Although community nursing services are frequently required to administer insulin, the type and extent of insulin safety issues encountered by such services, including those in the NPA report, are poorly documented. Objectives to audit the quality of directions to administer insulin/ medication administration record (MAR) charts against the NPA and other standard requirements to explore other aspects of insulin use and safety in community nursing to raise awareness of safety issues with use of insulins and facilitate implementation of the NPA Rapid Response Report afer administration of insulin before the December 2010 deadline Methods Audit data collection forms were developed by the Medicines Use and afety Division of the East and outh East England pecialist Pharmacy ervices. Following comment from specialist pharmacists and nurses working in several community trusts, the forms were piloted in a community trust in outh East Coast. Organisations across the pecialist Pharmacy ervices geography were invited to participate via presentations and e mails to established community services pharmacy networks and leads. Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 3

4 Medicines Use and afety Community nurse teams could conduct the audit on any 1 day between Nov 15 th and Dec15 th For each patient on insulin on the audit day, community nurse team members completed a 1 page audit form (appendix1). The form could be completed by any healthcare worker who administered insulin (e.g. community nurse, healthcare assistant, etc) when they visited the patient. The basic audit standards (see below) addressed the quality of documentation. However, the data forms also included other issues identified by community nursing services, such as use of different insulin administration devices, care plans and blood glucose testing. tandards Medicines administration charts/orders authorising nurses or other healthcare workers to administer insulin include the following: - Clear, correct full name of insulin preparation e.g. Humalog Mix25 - Dose to be administered clearly stated with no abbreviation used for the word units - Form/device used to administer insulin clearly stated e.g. vials, cartridges, disposable device - ignature of prescriber and date Results 19 Provider Trusts participated in the audit. Data were collected for 622 patients requiring administration of insulin. (London trategic Health Authority 10 trusts 441 patients; outh Central 1 trust 2 patients; outh East Coast 4 trusts 89 patients; and East 4 trusts 90 patients.) 14 trusts data, each including at least 20 patients, were also used for inter-trust comparisons (582 patients). Participating organisations and summary results are given in appendix 2 and 3 respectively. taff collecting the data were largely community nurses (460), no data was collected by healthcare assistants and there were only 2 reports of data being collected by other staff. Job role was not reported for 160 patients. Insulin name was reported for 616 patients and 20 patients required 2 insulin products. The 5 most commonly used products were Lantus (259 patients), NovoMix 30 (125), Mixtard 30* (57), Insulatard (48) and Levemir (33). hort acting insulins, such as NovoRapid, Actrapid and Humalog, were administered to 37 patients. A total of 16 insulin products were reported. The proportion of patients on the newer long-acting insulin analogues (Lantus and Levemir) varied considerably between trusts. [* Mixtard 30 was discontinued in the UK in December 2010.] The types of insulin administration devices used were sub divided into insulin syringes (258); prefilled disposable devices (e.g. Innolet, olostar, FlexPen) (178); cartridges for use with insulin pens (60); unspecified pen type device (52); not reported/unclear (74). There were 30 reports of syringes being used for insulins which are not available in vials. One respondent specifically commented that an insulin syringe was being used with a pen cartridge to reduce the risk of needle stick injury. ( A Medical Device Alert on the risk of needlestick injuries from pen devices was issued in ) The 14 trusts included in the comparative data showed marked variation in the use of insulin syringes as opposed to other administration devices, from 5.9% of patients to 82.6%, mean 43.4%. Medicines administration documentation Medicines administration charts/orders authorising nurses or other healthcare workers to administer insulin largely included the correct full insulin name, but 15/612 (2.5%) indicated that this was not present. The word unit was abbreviated on 97 occasions (15.7%) and on a further 24 occasions the dose was not clear. The insulin administration device was often not stated (54.1%) and occasionally the records were not signed and dated by the prescriber (7.7%). Prescription details such as product names and doses were frequently transcribed onto medicines administration records by someone other than the prescriber (69.2%). A comparison of the use of abbreviations for the term unit for 14 trusts reporting at least 20 patients is shown in Figure 1. Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 4

5 atients (percent) Patients (percent) P Medicines Use and afety Figure 1 Abbreviations for 'units' E M C B F L D N J I A K G H Trust Insulin administration Just over half the patients (51.1%) had insulin administered more than once each day. Insulin was administered on some occasions by someone other than the community nurse team for 20.3% of patients. There were 222 patients receiving insulin more than once a day where insulin was always administered by the community nurse team. On 83 occasions (13.4%) insulin devices were prepared by community nurses ready for injection by someone else. There were 19 reports (3.1%) of insulin syringes and needles not always being available and 8 reports that the nursing records of insulin administration were not accessible to other health workers visiting patients at home. The prescriber s administration authorisation was frequently separate from the record of medicines administered (82.0%). For 17% of patients, nurses reported using particular insulin administration devices without any training. Comparative graphs for frequency of insulin administration, preparing devices for use by others and device training are shown in figures 2, 3 and 4 respectively. Figure 2 Total patients who have insulin administered more than once a day M F J L D H C B I K E A G N Trust Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 5

6 atients (percent) Patients (percent) Patients (percent) P Medicines Use and afety Figure 2a Frequency of insulin administration and use of longacting analogues M F J L D H C B I K E A G N Trust insulin administered more than once a day long-acting insulin analogues Figure 3 Insulin prepared for administration by others K H I E C L B M F G D N A J Trust Figure 4 Use of insulin devices without any training C M E K B F H J A I N L G D Trust Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 6

7 Medicines Use and afety Comments on insulin administration *Nurses find it difficult to use the optiset - now using insulin syringes with vial provided by GP *Lives in Care Home - staff very competent. Why can they not be trained to administer insulin? *No problem as such, but patient has carers that could administer insulin but are not allowed by their employer. *Lives with family. Has carers. Family refuses to administer insulin *Risk assessment carried out - for weekly draw up for self-administration *Patient administers own insulin and does own blood sugar but needs prompting and supervision to achieve this. Family supervise at weekends. *Patient has self administered and over dosed recent 3 admissions with hypo Blood glucose testing Community nurses are frequently required to do blood glucose testing for patients requiring home insulin administration (93.2%) and the testing frequency is often (81.9%), but not always, specified in the patient records. Blood testing was conducted more than once a day for 44.3% of patients. However, specific actions to take in response to certain blood glucose levels were only documented for 54.5% of patients. Comments on blood glucose testing *Won't allow administration if BL less than 5mmol which can end up being over an hour visit after food prep and re-monitoring *Blood sugars change frequently and different health care professionals have different opinions on management Patient factors and other issues In response to an open question about the reasons patients were unable to self-administer insulin, many had poor vision, memory loss, physical disability or mental health issues. Other infrequent issues included patients being reluctant to self-inject (e.g. needle phobia), temporary help for new users, and communication issues (e.g. language and literacy). everal patients were able to selfadminister but required help setting up the administration device and some had occasional visitors (e.g. family members) who also administered insulin. There were occasional reports of diet problems, poor control of blood glucose and insulin refusal. Discussion This large scale audit of insulin administration by community nursing teams across outh and outh East England has demonstrated wide variation in many aspects of practice and insulin use between trusts. The data affords a basis for benchmarking local activity and can be used to drive both safety and cost improvement. Quality of documentation Basic standards for the quality of directions to administer insulin were frequently not met. There were occasional problems with insulin product names, but much more common was the use of dosage abbreviations or otherwise unclear doses. ince the audit was conducted, patient harm resulting from use of abbreviations for the word units when prescribing insulin has been classified as a never event which applies in all healthcare settings 9. Prior to this, safety issues resulting from the use of the abbreviation u had already been highlighted by the NPA and advice not to use abbreviations when prescribing insulin has been included in the BNF for many years. Whilst electronic prescribing systems may help overcome this problem, directions to administer insulin in the community largely Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 7

8 Medicines Use and afety continue to be hand written and action is essential to correct this problem before serious patient harm occurs. Use of abbreviations was much more common in some trusts where particularly urgent action appears to be required. The form or device used to administer insulin was often not included in administration directions, but whilst this is poor practice, it is likely that only one device will be available in the patient s home so device miss-selection is less likely than in other settings. There were a small number of cases (47) where the directions were not signed and dated by the prescriber. The Medicines Act 1968 does not specify that directions to administer prescription-only medicines need to be in writing so being signed and dated by the prescriber, as well as other details, are not required by legislation. However, written directions are accepted standard practice in community settings and should be signed and dated by the prescriber so the legal position of staff administering insulin is clear. Transcription of medicine details (e.g. insulin name and dose) onto medicines administration records by someone other than the prescriber is common and introduces the possibility of transcription errors. Whilst the Nursing and Midwifery Council recognises that there may be occasions where members need to transcribe directions to administer medicines, this should not be routine practice 10. Any such transcription should be checked by another health professional and there should be a rigorous policy to ensure the process meets local clinical governance requirements. [Guidance on transcribing has recently been produced by the East and outh East England pecialist Pharmacy ervices 11.] The documentation used by prescribers and community nurses also varies considerably between and even within trusts. The use of standard document formats which do not require routine transcription would prevent the possibility of transcription errors and help staff working across different trusts. Frequency of insulin administration Approximately half the patients in this study (318) had insulin injected more than once a day and most had to rely on the community nurse team for all insulin doses. Obviously such repeated visits to administer insulin require very significant commitment of time and resources by community nursing teams. However, the disparity between trusts in the number of patients requiring insulin more than once a day requires further consideration. Whilst there will be occasions where more than once daily dosage is necessary, it is unlikely that the observed variation could be totally attributed to individual clinical circumstances. NICE has indicated that use of long-acting insulin analogues can be appropriate for people who require assistance from a healthcare professional to inject insulin and where use would reduce injection frequency from twice to once daily 12. The results here appear to suggest that trusts with higher use of long acting analogues tend to have more patients managed with a once daily regimen. Thus whilst the newer analogues can be more expensive than traditional insulins, any additional cost may be offset by the reduced requirement for home visits by the community nurse team. Three trusts reported managing at least 60% of patients on only once daily insulin. If this could be replicated by the other trusts, the number of daily patient visits made by community nurse teams for insulin patients could be reduced. Furthermore, NICE has indicated that for type 2 diabetics a single bedtime dose of human isophane insulin (e.g. Insulatard) may be suitable, so a once daily regimen may be achieved without recourse to long-acting analogues 12. Of the 495 patients where all insulin doses were given by community nurses, 222 had insulin administered more than once a day (44.8%). If this could be reduced to 40%, there would be only 198 patients requiring home visits more than once a day, a reduction of 24 patients. The unit cost per home visit from a community nurse is about Thus the annual savings from this small change would be approximately 210,000 for the study population of 622 patients. Extrapolating these figures for a total UK diabetic population of 1.8 million with approximately 10,800 (0.6%) relying on third party insulin administration 14, suggests potential savings in excess of 3.5 million per annum. The Quality and Outcomes Framework (QoF) for general practice includes a requirement (Medicines 6) for practices to agree up to 3 actions related to prescribing. One such action might be for GPs to Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 8

9 Medicines Use and afety review all insulin patients managed by community nurse teams, agree with the team and the patient whether or not a once daily insulin regimen is suitable, and ensure directions to administer insulin meet the required quality standards. Preparation of insulin devices for use by others The Royal College of Nursing has produced guidance for community nurses on Advance preparation of insulin syringes for patients to administer at home 5. They report that although this practice appears to have gone on without notable problem for decades, it should only be used when there is no other viable alternative, using an agreed protocol to ensure patient safety (example standard operating procedure for pre-filling insulin syringes 15 ). It is interesting that there is significant diversity between trusts in the frequency with which this approach is used: assessing whether there is a viable alternative to advance preparation of syringes is open to interpretation by the professionals involved. Nevertheless the variation seen would suggest that the threshold used to determine whether advance preparation of insulin syringes is the best course of action shows little consistency between trusts. Insulin administration devices Insulin was administered by community nursing staff using a pen or other device slightly more frequently (52.9%) than using an insulin syringe and needle. There were at least 60 occasions where a pen with disposable cartridges was reported. In 2005 a Medical Device Alert from the Medicines and Healthcare Products Regulatory Agency advised that, because of the risk to healthcare workers of needle stick injury, such devices should be avoided wherever possible. However, this alert has now been withdrawn, stating no new incidents 16.afety needles for insulin pens which include a protective sheath (e.g. NovoFine Autocover, BD Autoshield) are now available. There were also a lot of patients where insulin was administered using one of the various disposable devices designed to aid patient self-administration. A patient death has been reported where a community nurse was unfamiliar with a particular insulin device (Opticlik) and the NPA has suggested that there should be a readily available source of training for staff to ensure competency 4. A training course linked to the NPA report afer administration of insulin has been made available across the NH, but the multitude of insulin devices encountered in the community would also require staff to have immediate access to specialist expertise. The practicalities of having expert support immediately available if a nurse attends a patient at home and encounters an unfamiliar device are not easily resolved. A better approach might be to use insulin syringes and needles for all patients who do not self-administer. Even if patients only require temporary input from the community nurse team, a case could be made for having both the self-administration system and vials prescribed, so team members do not have to be familiar with different devices. In nearly one in five cases community nursing staff reported that they had not received training about a device they were using. Not all insulins are available in vials and there were a number of reports of insulin syringes being used for insulins that are only available as pen cartridges. Whilst one insulin manufacturer contacted (Novo Nordisk Levemir) said that syringes could be used with pen cartridges, such use would be outside the product licence and the RCN guidance advises against this 5. The range of product forms (e.g. vials, pen cartridges, pre-filled disposable devices) needs to be carefully considered when selecting insulins for inclusion in local formularies and guidelines. Insulin administration by healthcare assistants and others There are a number of reports of healthcare assistants (HCA) being trained to administer insulin 17, but in this audit no patients were receiving insulin from an HCA. With the increasing incidence of diabetes and patients unable to self-administer, use of trained HCAs affords one means of meeting Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 9

10 Medicines Use and afety increased demand, but it appears not to have been widely adopted. There were also instances where other carers might be able to administer insulin, but some uncertainty as to how this might best be accomplished. The current pressure on all health budgets is such that careful consideration of the appropriate skills and skill mix in providing a home administration service will be necessary. Health profession leads need to further consider and support innovative practices which enable other groups, such as healthcare assistants and care workers, to administer insulin, and allay concerns about liability if errors occur. Blood glucose testing and patient issues Community nurses undertook blood glucose testing for nearly all patients, but only half had care plans which included actions to be taken in response to particular blood glucose levels. Nurses administering any medicine must consider whether to administer or withhold treatment in the context of the patient s condition 10. However, such decisions might also be guided by care plans and local protocols; there are anecdotal reports from various health sectors of insulin being administered despite low blood sugar levels. Common reasons for people being unable to self-administer insulin were failing sight, physical impairment or confusion/memory loss. A study in 1998 also reported that the main reasons why insulin patients in the community were incapable of self-care were state of mind (e.g. dementia, impaired mental health), visual impairment and poor dexterity 18. Patients who suffer confusion and memory loss present particular challenges, as diet and eating patterns may be erratic. The audit did not include patient age or whether type 1 or type 2 diabetes. However, as might be expected, descriptions suggested that most patients were elderly and required support from the community nursing team on a long-term basis. Audit limitations: NH trusts in East and outh East England volunteered to participate in the audit and chose which day to undertake the data collection, so findings may not be representative of other areas or other days. Results were self-reported by the nursing teams. Conclusions Where patients require insulin but are unable to self-administer, a range of clinical, logistical and safety issues need to be considered so that community nursing teams can provide an effective insulin support service. The results reported here suggest that many issues are frequently not reviewed in this context, resulting in some potentially unsafe and costly practices. NH diabetes has recently issued a report on insulin use in hospitals which recognises that when patients are discharged and unable to self-administer, careful discharge planning is necessary 19. This includes consideration of the frequency of insulin administration and timing of meals which may require alternative insulin regimes to those used during hospital admission. All patients requiring insulin administration by the community nurse team require specific consideration of the balances between good glucose control, quality of life and safe effective service provision. Carina Livingstone March 2011 Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 10

11 Medicines Use and afety 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: National Patient afety Agency. Rapid Response Report NPA/2010/RRR013; afer administration of insulin. upporting information. June Royal College of nursing. Advance preparation of insulin syringes for patients to administer at home. RCN guidance for community nurses data/assets/pdf_file/0010/619804/rcnguide_insulin_syringes_web. pdf 6. National Patient afety Agency. Rapid Response Report: afer administration of insulin. June Livingstone C. Pharmacy contribution to patient safety: Results of collaborative insulin baseline audit. East and outh East England pecialist Pharmacy ervices use-and-safety/patient-safety/learning-safety-solutions/insulin/report-collaborative-insulin- Baseline-Audit/ 8. Livingstone C & Nicholls J. Collaborative audit of pharmacy interventions which contribute to the safe use of insulin. UKCPA Autumn ymposium 2010 (in press) 9. Department of Health. The never events list 2011/12. Policy framework for use in the NH. February ce/dh_ Nursing and Midwifery Council. tandards for medicines management. April Green D. Transcribing. Guidance to support the safe and appropriate use of transcribing of medicines information for the purpose of recording administration of medicines in various health and social care environments. East and outh East England pecialist Pharmacy ervices England/Meds-use-and-safety/ervice-deliv-and-devel/Delivery-services-across- CH/Transcribing-Guidance/ 12. National Institute for Clinical Excellence. Type 2 diabetes: newer agents for blood glucose control in type 2 diabetes. NICE short clinical guideline 87. May National Institute for Clinical Excellence. Costing statement: Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults. ept Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 11

12 Medicines Use and afety 14. Trueman P et al. The cost of needlestick injuries associated with insulin administration. Br J Community Nursing 2008;13: Lambeth Torbay and outh Devon Health and Care NH Trust. Diabetes - Pre-loading of insulin syringes for adult patients to administer at home %20Pre%20Loading%20of%20Insulin%20yringes.pdf 16. Medicines and Healthcare products Regulatory Agency. Medical Device Alert: Pen injection devices and pen needles MDA/2005/009. February Now withdrawn 17. Owen M. Insulin administration in the community: a project. Br J Healthcare Assistants 2009;vol3: Pickstock P G, ingh B M. Assessing dependency in insulin-treated patients with diabetes supported by a community nursing team. Diabetes Care 1998;21: NH Diabetes. afe and effective use of insulin in hospitalised patients. March Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 12

13 Medicines Use and afety APPENDIX 1- Audit form Community nursing data collection form - (1 copy to be completed for each patient requiring administration of insulin by community nursing staff) Date: Completed by: Community Nurse/ Healthcare Assistant/ Other Name of organisation: Name of insulin: Name of device: Medicines administration authorisation Is this included? Clear, correct full name of insulin preparation e.g. Humalog Mix25 The term unit is clearly written in full i.e. not abbreviated The dose to be administered is clearly stated (*not including abbreviations for the word unit entered above) The time at which insulin doses are to be given is clearly stated Form/device used to administer insulin is clearly stated e.g. vials, cartridges, disposable device igned and dated by prescriber Yes/ No (y/n) Are prescription details (e.g. insulin name, dose etc) transcribed onto the medicines administration record by someone other than the prescriber? Insulin administration Does this patient have insulin administered more than once a day? Does anyone other than the community nurse team administer insulin to this patient? Do you fill a syringe or set up an insulin device ready for use by someone else? Is any necessary insulin syringe and/or needle always available? Are doses of medicines administered recorded on a sheet/book which is separate from the prescriber s administration authorisation? Are the nursing records of insulin administered accessible to any health professional during a home visit? Did you receive training about this particular insulin device before using it yourself? Yes/ No (y/n) Blood glucose testing Do you do blood glucose testing for this patient? Do the patient records indicate how frequently blood glucose testing is needed? Is testing usually done less than once a day? Is testing usually done more than once a day? Do the patient records or written protocols indicate specific actions to take in response to certain blood glucose levels? Yes/ No (y/n) What is the main reason the patient is unable to self-administer insulin e.g. poor eye-site, physical impairment etc? Please describe any other issues or problems you recall with insulin use for this patient APPENDIX 2- Participating organisations Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 13

14 Medicines Use and afety East of England Bedfordshire Community Health ervices Central Essex NH Great Yarmouth and Waveney Community ervices Norfolk Community Health and Care NH Trust London Brent Community ervices Central London Community Healthcare Trust Hounslow and Richmond CHC Lambeth Community Health NH Camden NH Croydon NH outhwark NH utton and Merton Outer North East London Community ervices Oxleas NH Foundation Trust outh Central NH olent outh East Coast West Kent Community Health ussex Community NH Trust Medway Community Healthcare East ussex Community Health ervices Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 14

15 Medicines Use and afety APPENDIX 3- Audit form with summary results (622 patients) Completed by: Community Nurse (460)/ Healthcare Assistant (0)/ Other (2)/not reported (160) Name of organisation: Name of insulin: Name of device: Medicines administration authorisation Is this included? Yes No Not reported Clear, correct full name of insulin preparation e.g. Humalog Mix The term unit is clearly written in full i.e. not abbreviated The dose to be administered is clearly stated (*not including abbreviations for the word unit entered above) The time at which insulin doses are to be given is clearly stated Form/device used to administer insulin is clearly stated e.g. vials, cartridges, disposable device igned and dated by prescriber Are prescription details (e.g. insulin name, dose etc) transcribed onto the medicines administration record by someone other than the prescriber? Insulin administration Yes No Not reported Does this patient have insulin administered more than once a day? Does anyone other than the community nurse team administer insulin to this patient? Do you fill a syringe or set up an insulin device ready for use by someone else? Is any necessary insulin syringe and/or needle always available? Are doses of medicines administered recorded on a sheet/book which is separate from the prescriber s administration authorisation? Are the nursing records of insulin administered accessible to any health professional during a home visit? Did you receive training about this particular insulin device before using it yourself? Blood glucose testing Yes No Not reported Do you do blood glucose testing for this patient? Do the patient records indicate how frequently blood glucose testing is needed? Is testing usually done less than once a day? Is testing usually done more than once a day? Do the patient records or written protocols indicate specific actions to take in response to certain blood glucose levels? Community nursing insulin report-vs.2.1-mar 11(CL) - links updated Dec 15 15