Intended for healthcare professionals

Rapid response to:

Practice Safety Alerts

Safer administration of insulin: summary of a safety report from the National Patient Safety Agency

BMJ 2010; 341 doi: (Published 13 October 2010) Cite this as: BMJ 2010;341:c5269

Rapid Response:

Re: Safer administration of insulin: summary of a safety report from the National Patient Safety Agency

Introduction: NPSA review on Insulin errors from November 2003 to November 2009 in England reported 16,600 errors via National report and learning service1. National In-patient Diabetes Audit, 2010 showed 60% insulin errors and 30% medication errors2. An e-learning module on safe use of insulin is freely available in NHS Diabetes website for all healthcare professionals for guidance and support for the safe use of insulin. A competency based assessment undertaken among 40 Foundation Year 1 (FY1) trainees in City Hospital, Sunderland had demonstrated improvement in Insulin prescribing errors after completion of this e-learning module3.

Aim: To create and raise awareness of the Safe use of insulin e-learning module on NHS diabetes ( by three surveys in 4 months aiming for 100% completion rate by the end.
Method: The survey was carried out at three time points from January 2011 to April 2011. Over this period of time, there were also 6 sessions of teaching addressing various aspects of Diabetes and Endocrinology. All attending FY1 doctors filled the anonymised survey forms, during their weekly compulsory teaching sessions.

Results: Overall, 72 % of the FY1 trainees responded to the survey. Figure 1. describes the progressive improvement of confidence in insulin prescribing, awareness about the e-learning course and completion of the course over the time period. Common reasons cited for non-completion of the course were – ‘lack of time’, ‘forgotten’ and ‘procrastination’.

Conclusions: There was a significant and progressive improvement in the confidence level of insulin prescription and all FY1 trainees were aware of the e-learning module by the third survey. However, the completion rate was dismal. Though the majority of the FY1 trainees had completed the course, the reasons cited for non-completion of the course, which this year had been voluntary, is concerning. The results suggests a group of young doctors, who are aware of their lack of confidence in prescribing insulin as well as the availability of a course which will specifically improve their knowledge and thereby their ability to do so, has been failing to complete this. The reasons cited may suggest one of the following: a) they do not have this time during their working day to complete the course, b) ‘willful ignorance’ or c) unsuitable for ‘adult learning’, principles of which supports web-based education programmes as this e-learning course. In some hospitals, this course has been made compulsory for all the new FY1trainees, but we need to address the reason of their non-completion so that it does not have far reaching consequences.

1. Patient Safety Alert NPSA/2011/PSA003.
3. Sinha R, Jones A, Nayyar R. Safe insulin prescribing and competency-based assessment – Practical Diabetes International 2011; 28:138

Competing interests: No competing interests

13 June 2012
Moulinath Banerjee
Consultant: Diabetes & Endocrinology
Dr. Chandra Rai
Cumbria Diabetes & University Hospitals of Mrecambe Bay NHS Foundation Trust
Furness General Hospital, Dalton Lane, Barrow in Furness LA14 4LF