Procedure for the prescribing and administration of insulin

Transcription

1 Procedure for the prescribing and administration of insulin Author: Lilian Baxendale and Heather Beadle Designation: Clinical Governance Pharmacists Version: Version 3 Date: December 2016 Date Approved: 13 th January 2017 Approved By: Drugs and Therapeutics Committee Lead Director: Sharon Binyon Review Date: January 2019 Name of responsible committee / individual: Target Audience: Page 1 of 6

2 1. Introduction and Background Deaths and severe harm incidents have resulted from administration errors with insulin products. In general, using insulin is safe. However, there is a potential for serious harm if it is not administered and handled properly. Safety issues with insulin use may arise from: A lack of vigilance to prevent medication errors, resulting in use of the wrong insulin products Poor systems for managing insulin therapy in hospitals A lack of education and access to information about diabetes management including: o The safe use of insulin o Injection technique o Hypoglycaemia o Hyperglycaemia Lack of patient awareness of the symptoms of hypo and hyperglycaemia Poor monitoring and adjustment of insulin doses. Common causes of errors with insulin are inaccurate dosing and administration, resulting in too much circulating glucose (hyperglycaemia) or too little circulating glucose (hypoglycaemia). The National Patient Safety Agency (NPSA s) National Reporting and Learning System (NRLS) received 16,600 incidents involving insulin between November 2003 and November These included six deaths and twelve severe harm incidents. Analysis of the incident reports indicated that there are three main types of errors accounting for over 60% of all incidents reported: Patient getting the wrong insulin product(s) Having insulin omitted or delayed Getting the wrong dose of insulin The NPSA issued an alert in June 2010 Safer administration of Insulin. This alert made various recommendations to reduce the risk to patients when insulin is prescribed and administered. These included: All regular and single insulin (bolus) doses to be measured and administered using an insulin syringe or commercial insulin pen device, The term units to be used in all contexts with abbreviations such as U or IU never to be used, A training programme for all healthcare staff prescribing, preparing and administering insulin, and all clinical areas/community staff treating patients with insulin to have adequate supplies of insulin syringes and subcutaneous needles. A further patient safety alert was issued in March 2011 The Adult Patient s passport to the safer use of insulin. The aim of this alert was to improve patient safety by empowering patients to take an active role in their treatment with insulin. This will be achieved with a patient information booklet and a patient-held record (The Insulin Passport). An additional patient safety alert was issued in November 2016 Risk of severe harm and death due to withdrawing insulin from pen devices. The aim of this alert was to draw attention to the risks of extracting insulin from insulin pens or insulin cartridges prior to administration. Although most insulin pens/cartridges are available in a strength of 100units/ml, some insulin pens/cartridges are available in different strengths e.g. 200 units/ml. Insulin syringes have graduations only suitable for calculating doses of standard 100units/ml. If insulin extracted from a Page 2 of 6

3 pen or cartridge is of a higher strength, and that is not considered in determining the volume required, it can lead to a significant and potentially fatal overdose. 2. Purpose The purpose of this procedure is to ensure the safe prescribing and administration of insulin within the Trust. All activities carried out in relation to this procedure should be delivered in a nondiscriminatory manner and respect the individuality and diversity of the patient. 3. Linked Documents This procedure should be read in conjunction with other related Trust policies and procedures, including the Medicines Policy, Policy for Standard Infection Control, Procedure for Medicines Reconciliation on Admission to Inpatient Units, Safe use and Disposal of Sharps. 4. Responsibility All staff involved with the prescribing and administration of insulin are responsible for ensuring that they are aware of and understand this procedure and are aware of their responsibilities and accountabilities as laid down within their professional code of conduct. 5. Medicines Reconciliation 1. It is essential that the insulin prescribed is the correct insulin type, the correct dose and the correct delivery device (e.g pen, vial) for the patient. For inpatients, this check should be made by following the process detailed in the Procedure of Medicines Reconciliation on Admission to Inpatient Units. Within Integrated Community Services/ Child and Family Services, nursing staff will be responsible for this check at the point of transfer of care. This check should include reference to the patient s Insulin Passport for confirmation of the upto-date insulin prescription. If there is a discrepancy between the Insulin Passport, a patient s notes or current understanding of insulin therapy, it should be reconciled and the information in the Insulin Passport updated. If a patient does not have an Insulin Passport and patient information booklet, these should be issued to the patient. Prescribers are also responsible for issuing replacement Insulin Passports where there is no space left for new information, or if the passport has been lost or has become unreadable. Patients should be given the opportunity to discuss the content of the patient information booklet with a healthcare professional. Insulin Passports and Patient Information Booklets are both available from the Medicines Management Department at Wayside House ( ). 6. Prescribing of Insulin 1. Prescribers must follow the Trust Medicine Policy when prescribing insulin. Particular care must be taken to write the word unit in full (see MMG2 of the Medicines Policy) on the prescription/administration sheet. The use of abbreviations for unit has resulted in patient safety harm incidents. Page 3 of 6

4 If a prescriber changes a patient s insulin prescription, patients will need to update their Insulin Passport. The prescriber or another healthcare professional must be available to assist the patient in completing the Insulin Passport. 2. The proprietary/brand name of insulin should be recorded on the prescription/administration sheet. 3. In in-patient/bedded units Glucogel should be prescribed on the PRN section of the prescription/administration chart, in case of hypoglycaemia. 7. Administration of insulin 1. Nurses should not administer the insulin unless the prescription chart/authority to administer chart has been clearly written in accordance with the Medicines Policy (see section 3 above). The nurse should check/confirm that the patient has an Insulin Passport, and that the information in the current prescription matches the passport. If there are any discrepancies, the prescriber should be consulted. The Medicines Management Technicians and Pharmacists also have a responsibility to check/confirm the presence of an Insulin Passport and the accuracy of the prescription chart in areas that receive routine visits. 2. If there is any doubt about the prescription, the prescriber should be contacted. If out of hours the relevant out of hour s processes for that team should be accessed. 3. Insulin is generally administered subcutaneously. The injection site should be rotated to prevent lipodystrophy. 4. Insulin pens are patient specific; they should be labelled with the patient s name, and only used for that patient. 5. Nurses administering insulin must ensure that the dose and type of insulin prescribed is correct, and should familiarise themselves with the delivery device e.g insulin pen. They should seek additional help/support if they are unsure of the delivery device, to ensure that the correct dose is administered. 6. Insulin pen needles should not be resheathed by the administering nurse. It is recommended that a device such as BD Autoshield Duo Safety Pen Needle (a universal fit for BD pens), or a needle removing device such as Novofine Needle Remover should be used to remove insulin pen needles safely. Some larger sharps bins contain a facility in their lid which allows for safe removal of needles. 7. If a syringe and needle are required to draw the dose from a 100 unit per ml multidose vial, a U100 insulin syringe must be used. Under no circumstances should an intravenous syringe be used, as this may lead to dosing errors. 8. Due to the availability of different strengths of insulin within insulin pens and insulin cartridges, staff should never withdraw insulin from insulin pen devices or cartridges. 9. The nurse should ensure the appropriateness of insulin administration times in relation to food intake where appropriate e.g. the rapid-acting human insulin analogues (insulin aspart, insulin glulisine, insulin lispro). 10. In services or areas where the patient needs to be assessed for self administration, the patient will be assessed by the nurse to be competent to draw up/measure the dose of insulin using the delivery device (as appropriate) and administer the insulin themselves. In in-patient areas/bedded units administration should be recorded on the prescription/administration sheet or authority to administer chart as SA (self administration). Page 4 of 6

5 Where it is considered appropriate for a patient is to self-administer within an inpatient setting, nursing staff should ensure that necessary equipment such as blood glucose monitoring devices for self monitoring of blood glucose, bedside lockers and sharps disposal facilities are confirmed as available (see Medicines Policy, MMG 11). The patient care plan must take into account complex situations when patients will require short-term help with their insulin administration. E.g. when patients are sedated, temporarily incapable of taking decisions or misunderstand situations such as nil-by-mouth. Nursing staff should be vigilant for such error prone situations. 11. The patients blood glucose level should be checked prior to administering and if below 4.0mmols insulin should not be given and advice sought. Monitoring of glucose levels should be undertaken as required in the patient s care plan. The patient should be monitored for the emergence of hypo- or hyper-glycaemia and the nurse should take appropriate action if either of these occurs. 12. If the wrong dose of insulin is administered, staff should take appropriate action to ensure the safety of the patient. An assessment of the patient should take place, including checking blood sugar levels at appropriate regular intervals. The emergency services should be contacted urgently if necessary. See the Resuscitation pages of the Trust Intranet for a glycaemic emergencies procedure. 13. An intravenous insulin infusion is unlikely to be administered within the Trust. However, If this is prescribed in exceptional circumstances, a U100 insulin syringe must be used to measure and prepare the 100 unit/ml insulin required for this infusion. Page 5 of 6

6 8. Training/competencies All staff who prescribe for, or administer to, patients requiring insulin therapy must have training to ensure that they have the necessary competency. An e-learning programme is available at 9. Dissemination and implementation Once approved, the procedure will be made available on the intranet. Notification of its release will be made via all user s/trust Team Brief for cascade to all staff members. Ward/unit managers will be responsible for its implementation on their areas. 10. Equality Impact An equality impact assessment of this procedure will be carried out prior to ratification. 11. Monitoring Key aspects of his procedure will be audited with regard to compliance, initially annually. 12. References 1. NPSA/2010/RRR013 Rapid Response Report Safer administration of Insulin 16 th June Insulin prescribing and administration for insulin dependent diabetics in healthcare units (version 3) Hampshire Partnership Trust February NPSA/2010/RRR009 Rapid Response Report Reducing harm from omitted and delayed medicines in hospital 24th February NPSA/2011/PSA003 Patient Safety Alert The adult patient s passport to the safer use of insulin. 30 th March NHS/PSA/W/2016/011 Patient Safety Alert Risk of severe harm and death due to withdrawing insulin from pen devices 16 th November 2016 Page 6 of 6