NPC Archive Item: New Insulin safety guidance issued to reduce wrong dosages

NOTE – This is an archive post from the NPC and has not been updated since first publication. Therefore, some hyperlinks may no longer be working.

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26 July 2010

In June 2010, the National Patient Safety Agency (NPSA) issued its Rapid Response Report: Safer administration of insulin,1 which outlines supporting information2 aimed at reducing the number of wrong dose incidents involving insulin. In its supporting information2, the NPSA highlights that insulin is frequently included in the list of the top 10 high-alert medicines worldwide, indicating the high risk of patient injury if it is misused.

In the report the NPSA recommends the following action points be completed by all organisations in the NHS and independent sector:

  1. All regular and single insulin (bolus) doses are measured and administered using an insulin syringe or commercial insulin pen device. Intravenous syringes must never be used for insulin administration.
  2. The term ‘units’ is used in all contexts. Abbreviations, such as ‘U’ or ‘IU’, are never used.
  3. All clinical areas and community staff treating patients with insulin have adequate supplies of insulin syringes and subcutaneous needles, which staff can obtain at all times.
  4. An insulin syringe must always be used to measure and prepare insulin for an intravenous infusion. Insulin infusions are administered in 50ml intravenous syringes or larger infusion bags. Consideration should be given to the supply and use of ready to administer infusion products e.g. prefilled syringes of fast acting insulin 50 units in 50ml sodium chloride 0.9%.
  5. A training programme should be put in place for all healthcare staff (including medical staff) expected to prescribe, prepare and administer insulin. An e-learning programme is available from NHS Diabetes:
  6. Policies and procedures for the preparation and administration of insulin and insulin infusions in clinical areas are reviewed to ensure compliance with the above.

The deadline for completion of these action points is 16th December 2010.

Between August 2003 and August 2009 the NPSA received 3,881 wrong dose incident reports involving insulin. These included one death and one severe harm incident due to 10-fold dosing errors from abbreviating the term ‘Unit’.1,2

Three deaths and 17 other incidents between January 2005 and July 2009 were also reported where an intravenous syringe was used to measure and administer insulin.1,2

What does this mean to medicines management?
Healthcare professionals and managers involved in the care and treatment of diabetic patients should work together to establish clear policies and procedures that meet the recommendations identified by the NPSA for the safer administration of insulin.

The training principles for safer administration of insulin need to be agreed and fully understood by all staff. To coincide with the issue of this Rapid Response Review, NHS Diabetes has launched a new e-learning course, aimed at healthcare professionals, on the safer administration of insulin. The NHS Diabetes website supports its e-learning course with further information, advising people to check before they inject insulin, ensuring that they have the:

  • Right insulin – check the name.
  • Right dose – check strength and how much insulin to give. Check the numbers very carefully.
  • Right time – with food? At bedtime?
  • Right way – via syringe, pen or pump?

NHS Diabetes also advises that those administering insulin should “always ask the patient – show them the insulin and what you are about to do”.

Learning from previous incidents like those reported in the Rapid Response Report supporting information is essential, and ensuing steps need to be taken to minimise those risks such as: double checking insulin doses before administration; giving staff lighter workloads at insulin administration times; and putting effective communication and recording systems in place.

How does this relate to other publications or evidence?
The NPSA’s Rapid Response Report: Reducing harm from omitted and delayed medicines in hospital4 identifies the timeliness of insulin administration to be a further critical factor for patient safety. Therefore, medicine management procedures for insulin should include guidance on the importance of prescribing, supplying and administering, timeliness issues and what to do when insulin has been omitted or delayed.

The NPC e-learning resource NPC has a whole floor dedicated to patient safety and risk with supporting medicines management information on reducing medication errors and  reducing risk.

1. National Patient Safety Agency (2010). Rapid Response Report NPSA/2010/RRR013: Safer administration of insulin

2. National Patient Safety Agency (2010). Rapid Response Report NPSA/2010/RRR013: safer administration of insulin – supporting information

3. NHS Diabetes: Safe Use of Insulin. Available at:

4. National Patient Safety Agency (2010). The Rapid Response Report NPSA/2010/RRR009: Reducing harm from omitted and delayed medicines in hospital

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