ADMINISTRATION OF INSULIN

STANDARD OPERATING PROCEDURE ADMINISTRATION OF INSULIN Issue History First issued April 2012 Issue Version Two Purpose of Issue/Description of Change Planned Review Date To promote the safe administration of insulin for patients 2014 Named Responsible Officer:- Approved by Date Medicines Governance Pharmacist Quality, Patient Experience and Risk Group September 2012 Section:- Medicines Management SOPMM 11 Target Audience Registered UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION

CONTROL RECORD Title Safe Administration of Insulin Purpose To promote the safe administration of insulin for patients Author Quality and Governance Service (QGS) and L Knight Impact Assessment Completed Yes No Actions Required Yes No Subject Experts Lisa Knight / Annie Baker Document Librarian QGS Groups consulted with :- Medicines Management Group Infection Control Approved YES Date formally approved by the 5 th September 2012 Quality, Patient Experience and Risk Group Method of distribution Email Intranet Archived Date: April 2012 Location: S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 Medicines Governance Pharmacist R Additional final check added to draw up insulin and check the amount of insulin drawn up against the PMAC to ensure the correct dose Version 2 Medicines Governance Pharmacist R prior to administration Additions to document to comply with the National Patient Safety Alert NPSA/2011/PSA003 Status New / Revised / Trust Change 2/10

NAME OF DIS C IPLINE : NUR S ING OB J E CTIVE S SCOPE TARGET GROUP (Staff who are authorised to follow standard operating procedure) CROSS REFERENCE R E L ATE D POLIC IE S EVIDENCE TO SUPPORT PROCEDURE To promote the safe administration of insulin for patients To cover all aspects of insulin administration, except the advanced preparation of insulin (see separate standard operating procedure) All registered nurses employed by the Trust involved in the administration of insulin Policies and Procedures Safe Handling and Administration of Medicines Policy Standard Operating Procedure for Medicine Administration Procedure for the Administration of Medication by Intra Muscular Route and Subcutaneous Route Incident Report Policy Record Keeping Procedure for Community Nursing Standard Operating Procedure (SOP) for Advanced Preparation of Insulin Procedure for Blood Glucose Monitoring Infection Control Policies Consent Policy NMC Standards for Medicine Management (2010) National Patient Safety Agency (2010) Rapid Response Report NPSA/2010/RRR013: Safer administration of insulin National Patient Safety Agency (2011) Patient Safety Alert NPSA/2011/PSA003: The Adult Patient s Passport to Safer Use of insulin PROCEDURE ACTIVITY RATIONALE RESPONSIBILITY 1. COLLECT PATIENT INFORMATION Nursing Staff could be requested to administer insulin to patients or to support self administration. It is essential that the nursing role is clearly defined in the patient s care plan It is important that the nurse is familiar with the type of insulin prescribed There are also several insulin devices available on the market, it is essential that the registered nurse is also familiar with the device prescribed. Whenever possible nurses should familiarise themselves with the insulin device in advance of seeing the patient. If nurses are unsure how to operate an insulin device, they must seek additional advice and support. To ensure appropriate treatment Different insulins have different onsets and durations of action To reduce risk of administration error To allow time to read manufacturer s instructions must work within their competency to reduce error Registered nurse 3/10

Always follow the manufacturer s instructions; each insulin device will have a manufacturer s user guide. If this information is not available in the nursing base, it will be supplied when the device is supplied to the patient, alternatively the manufacturer could be contacted for specific advice if an unfamiliar device has been prescribed and the user guide is not available. A copy of the manufacturer s instructions should be filed in patient s base and home records. Where appropriate the choice of device may be discussed with the prescriber or the Diabetic Specialist Nurse (DSN) if under care of a consultant The preferred devices for administration of insulin by a community nurse are disposable pens or insulin vials. The nurse should request to see the patient s Insulin Passport to confirm that the correct insulin product has been dispensed. If the patient does not have an Insulin Passport, where appropriate the nurse should confirm the product with the patient or carer. To promote safe use of device Copies are also available on www.medicines.org.uk The prescriber will ensure appropriate device selection Pens with cartridges are slightly more difficult to use To reduce risk of administering an incorrect insulin with a similar sounding name For patients who do not have an Insulin Passport or the passport needs updating refer to section 11 2. CONS E NT Discuss risks and benefits of administration with the patient. Encourage the patient to read the manufacturer s patient information leaflet for full details of the insulin prescribed Patients can withdraw consent at any time To gain informed consent and document in patient s record Patients retain right to withdraw consent Registered Nurse 3. CHECK P ATIE NT ME DICINE S ADMINIS TR ATION CHAR T (PMAC) must check the Patient Medicines Administration Previous incidents show this step in Chart to ensure the dosage has not changed the safe administration of insulin was not completed resulting in medication errors Registered Nurse must also check the Record Chart of Insulin Administration and Blood Glucose Recording form to check the insulin has not already been administered Previous incidents have highlighted that if this step is not completed, patients have received double the dose of insulin The Patient Medicines Administration Chart must specify the following: 4/10 To reduce potential error (NPSA RR013)

Patient s full name Patient s date of birth The prescriber s signature and date prescribed The name of the insulin to be administered. (check the dispensed medicine is the same insulin as written on the PMAC) The device prescribed The number of units to be administered with word unit written out in full, in lower case and a space left between the dose and the word unit. The time and frequency of administration. (In some incidences the prescriber will indicate an appropriate window of time for administration. This needs to be on an individual patient basis. It is important to note, all regular doses of insulin should aim to be administered at the same time each day, including long acting insulins such as insulin glargine ) The route of administration i.e. subcutaneous injection Any known allergies Where there are any ambiguities the prescriber must be contacted for clarification It is also now recommended that the patient s NHS number is included on the PMAC 4. S TOR AG E OF INS ULIN Instruct the patient to store the insulin according to the manufacturer s instructions, insulin not in use should generally be kept in the main part of the refrigerator at 2 to 8ºC, not at the back of the fridge. Instruct patient to refer to the manufacturer s instructions for storage of insulin that is in use. To ensure the correct device is used for the patient The use of abbreviations have resulted in administration errors (NPSA RRR013) Failure to administer within the correct time interval may be detrimental to the patient. To comply with NPSA Safer Practice Notice To ensure safe storage of insulin Some insulins should not be stored in the fridge, when in use. Insulin that is in use and administered by the nursing service must be labelled with: 1. The full name of the patient 2. The date of commencement of the vial or pen (the date opened) 3. The date after which the insulin should no longer be administered. (the do not use after date) The name of the insulin, manufacturer s expiry date and the batch number must not be obscured with the additional label Each base will hold a supply of preprinted labels There may be situations where more than one person is prescribed insulin within a household or Care Home Insulin stored out of the fridge must usually be used within 28 days refer to manufacturer s literature for further details To ensure essential information is available. 5/10

The do not use after date and the manufacturer s expiry date, should be recorded on the Record Chart of Insulin Administration and Blood Glucose Recording form. Any expired insulin must be discarded. (see section 9) 5. PR E PAR ATION OF INS ULIN Collect together all essential equipment including, PMAC, Record Chart of Insulin Administration and Blood Glucose Recording form, insulin product to be administered, needles or if administering from a vial, insulin syringes. Decontaminate hands prior to procedure should not mix different insulins in the same syringe for administration. (For patients who have previously been prescribed insulin mixed in this way refer to the Diabetic Specialist Nurse for advice) Insulin must not be withdrawn from a cartridge via a syringe Always follow the manufacturer s instructions for the insulin device prescribed If using pen devices the needle must be changed prior to each administration A device specifically manufactured for the removal of needles should be used to change the needle If using vials, only insulin syringes must be used 6. ADMINIS TR ATION Check the time and frequency of the insulin administration (if the prescriber has indicated an appropriate window of time for administration this should be followed. In the absence of specific instructions nurses must administer insulin within one hour of the authorised time, this also applies to long acting insulin s, such as insulin glargine) If the prescribed time for administration has lapsed, the prescriber or other prescriber with responsibility for clinical care must be contacted for advice. The incident must be reported using the Trust incident reporting system. Ensure you are certain of the identity of the patient to whom the medicine is to be administered, by asking the patient and checking all available patient identifiers, such as name, date of birth or address To maintain an audit trail To ensure all necessary equipment is available To reduce the risk of transfer of transient micro organisms on the health care worker s hands To reduce risk of administration errors To reduce errors Certain devices require priming, prior to administration To prevent infection To reduce the risk of inoculation injury To reduce the risk of error Failure to administer within the correct time interval may be detrimental to the patient Additional blood glucose monitoring and or dose adjustment may be required To reduce administration errors 6/10

Check that the prescribed dose has not already been given, check Record Chart of Insulin Administration and Blood Glucose Record form first Extra care is needed when patients are prescribed two different doses of a particular insulin at different times of the day This is essential to reduce duplicate administration There have been several reported incidents where nurses have administered morning doses in the afternoon Check details on the PMAC correspond to pharmacy label Check manufacturer s expiry date and also if the insulin is already in use, check the do not use after date. Know and understand the contents of the current care plan for the administration of insulin (this must be updated every six months or earlier if health needs change) Draw up insulin and check the amount of insulin drawn up against the PMAC to ensure the correct dose prior to administration Where a patient is competent to do so, ask if the patient would like to double check the dose of insulin to be administered Comply with the Trust SOP for Administration of Medicines Administer the insulin by subcutaneous injection according to manufacturer s instructions In the event of nursing staff being unable to administer insulin as prescribed, it is essential that urgent advice is obtained from either, the patient s General Practitioner (GP), GP Out of Hours Service or the Registered Nurse s line manager depending on clinical circumstances. Reasons for insulin not been administered as prescribed could include: * Difficulties with the device * Unavailability of insulin * If there has been a significant delay in the time of administration The nurse must ensure adequate supplies of insulin are in the patient s home or on order to arrive in time for the next scheduled administration of insulin Decontaminate hands following procedure To reduce risk of expired stock being administered To deliver patient s health needs To ensure the correct dose of insulin is administered To empower the patient to take an active role in their treatment To reduce the risk of administration error To comply with safe practice It is imperative that the patient receives their insulin as prescribed. Delays in the administration of insulin may require the prescriber to adjust the dosage of insulin and extra monitoring of the patient may be required To reduce unsuccessful home visits or time wasted getting a new prescription and delaying administration of insulin the incident would need to be reported using the Trust incident reporting system. 7/10

If attending a care home Particular care is essential to check the identity of the patient The registered nurse must complete all checks and not rely on care staff. It is therefore strongly recommended that the registered nurse removes the insulin from the fridge her/himself. Ensure treatment occurs away from any distractions ideally in a separate treatment room with no other patient/resident in the same room 7. DOCUMENTATION Immediately after administration of the insulin, make a clear and accurate record of the administration on the Record of Insulin Administration and Blood Glucose Recording Form. must record information directly off the insulin product from the pen or the vial at each administration It is essential that nurses also record administration on the care home s Medicines Administration Record (MAR) Chart for cross reference 8. DIS POS AL OF SHARPS All sharps to be disposed of in an appropriate yellow lidded sharps container Sharps container will be provided by Community Nursing if the patient is on a Community Nursing Caseload. Becton, Dickinson and Company safe clip device should be used by the patient when away from home to dispose of the needle if appropriate Needles for disposal must not be resheathed, needles are to disposed of in the sharps container 9.DIS POS AL OF INS ULIN NO LONGER IN US E Advise patient to arrange for expired stock to be returned to the community pharmacy There may be residents within the home with similar names To reduce risk of medication errors To promote dignity and respect and reduce risk of medication error To ensure a robust audit trail and to reduce the risk of administration error To reduce the risk of inaccurate information being recorded The care home requires a record of all medicines administered to residents To comply with Sharps safety and management of contamination injuries policy Reduce risk of inoculation injuries To ensure safe disposal of medicines 10. ENSURE PATIENT HAS AN UP TO DATE CAR E PLAN Ensure patient has an up to date care plan which To ensure the care plan and insulin includes the actions to be taken in the event of dosage is current to the clinical need hypoglycemic or hyperglycemic episodes. The care plan must include who has clinical responsibility should any adverse clinical episode occur, as treatment may need to be adjusted in conjunction with the diabetic nurse specialist/ medical practitioner. All communications and actions taken must be evidenced in the patient s health records 8/10

Outside of core working hours (OOH), contact GP Out of Hours service. Ensuring all details of consultation are recorded in the patient s records and shared with the day staff To ensure all members of multidisciplinary team are updated Night staff are responsible for updating day staff of clinical concerns 11. PATIENTS WHO DO NOT HAVE INSULIN PASSPORTS OR THEIR PASSPORT REQUIRES UPDATING All patients prescribed insulin over the age of 18 To comply with NPSA/PSA/003 should be offered an Insulin Passport and the Trust s supporting patient information leaflet, The Safe Use of Insulin and You Registered nurses can supply patients with an Insulin Passport and supporting patient information leaflet, if they do not have a passport or their passport is misplaced. If a nurse issues an Insulin Passport and supporting patient information leaflet, the nurse must support the patient in completing the information on the passport, or complete the information required on the patient s To promote understanding behalf. The nurse should read through the leaflet with the patient and/or carer. It is also essential that the registered nurse informs the For the GP to document that an Insulin patient s GP if an Insulin Passport has been issued Passport has been issued If an error is detected on the Insulin Passport that could potentially lead to an administration error, this should be reported via the incident reporting system and the incorrect entry must be clearly crossed out. If the Insulin Passport requires updating, the nurse should support the patient in updating the passport or alternatively, update the passport on the patient s behalf. Any amendments made by the nurse must be clearly signed for and dated. If it is felt that it is inappropriate to issue an Insulin Passport or the patient refuses, this must be clearly documented in the patient record. 12 CLINICAL INCIDENT OR NEAR MISSES Any clinical incident or near misses must be reported using the Trust incident reporting system To help prevent future clinical incidents and learn from near misses in conjunction with the patient and or carer nurses 9/10

TR AINING SPECIALIST COMPETENCIES OR QUALIFIC ATIONS CONTINUING E DUC ATION & TR AINING RISK ASSESSMENTS ORGANISATION DEPARTMENT (IF APPLICABLE) employed by the Trust will work to the Standard Operating Procedure and related policies and procedures. All registered nurses will have completed their self assessment for Competency for Medicines Management within 3 months of joining organisation and updated two yearly Staff will have completed diabetes e-learning course within 3 months of joining Trust Staff will have attended Essential Learning every two years Staff will have attended Medicines Management Training every two years Staff will be aware of and comply with manufacturers instructions for specific medication and devices Staff have access to specialist nurses, line managers, General Practitioners and the Medicines Management Team for ongoing advice as required Risk of administration errors, risk of needle stick injuries Risk Assessment of patients with short term memory loss must be completed and updated every 6 months or earlier if clinical needs change Wirral Community NHS Trust Community Nursing STANDARD OPER ATING PR OCE DUR E (S OP) APPROVED BY:- Peer Review Forum Medicines Management Group Formal Approval Quality, Patient Experience and Risk Group 10/10