Sentinel 5 Patient given a Distraction of staff, associated with ward Review processes for safe use of insulin Diabetes specialist nurses times overdose of two rebuilding and refurbishment. in ward; eg, using only insulin pens. attended pharmacy and different types of ward to do training. elected not to use insulin pen for Educate nurses about correct use of insulin. administration. abbreviations and no use of in any Insulin pens which are ‘u’ documentation. able to give half units are Insulin not stocked on ward. now more freely available. Educate doctors on safe insulin Improved staff awareness Dose of insulin to be given written as ‘u’ prescribing as part of medical staff (RMO of their utility and use instead of general acceptance of ‘units’; responsible medical officer) education – monitored through auditing wrong abbreviation by doctors and programme. of medication charts. nurses. Develop systematic process for Safe prescribing practices Doses prescribed as and and ‘1U’ ‘2U’, identifying and managing staff workload misread as and respectively. (eg, use of full word 'units') ‘10’ ‘20’ issues on real time basis. are covered in pharmacy Perceived high staff workload. teaching to doctors. Safety alert sent out about necessity to prescribe using the word 'units' rather than using an abbreviation. Care Capacity Management programme will assist in determining workload issues and better matching resources to demand.
Sentinel 5 Patient given a overdose of two different types of insulin. Distraction of staff, associated with ward rebuilding and refurbishment. elected not to use insulin pen for administration. Insulin not stocked on ward. Dose of insulin to be given written as ‘u’ instead of ‘units’; general acceptance of wrong abbreviation by doctors and nurses. Doses prescribed as ‘1U’ and ‘2U’, and misread as ‘10’ and ‘20’ respectively. Perceived high staff workload. Review processes for safe use of insulin in ward; eg, using only insulin pens. Educate nurses about correct use of abbreviations and no use of ‘u’ in any documentation. Educate doctors on safe insulin prescribing as part of medical staff (RMO – responsible medical officer) education programme. Develop systematic process for identifying and managing staff workload issues on real time basis. Diabetes specialist nurses attended pharmacy and ward to do training. Insulin pens which are able to give half units are now more freely available. Improved staff awareness of their utility and use monitored through auditing of medication charts. Safe prescribing practices (eg, use of full word 'units') are covered in pharmacy teaching to doctors. Safety alert sent out about necessity to prescribe using the word 'units' rather than using an abbreviation. Care Capacity Management programme will assist in determining workload issues and better matching resources to demand. times