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Feature

The BMJ Awards 2018: Patient Safety Team of the Year

BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k1699 (Published 04 May 2018) Cite this as: BMJ 2018;361:k1699
  1. Nigel Hawkes, freelance journalist
  1. London, UK
  1. nigel.hawkes1{at}btinternet.com

Continuous learning and improved communication are common themes among this year’s shortlisted projects, reports Nigel Hawkes

Diabetes-safe accredited trust

When a high prevalence disease is treated using a high risk drug, the scene is set for mistakes, some of them potentially fatal. So it is with diabetes, and especially in Birmingham where the ethnic mix means that one in three patients admitted to Sandwell and West Birmingham Hospitals has diabetes.

Parijat De, consultant physician in endocrinology, diabetes, and lipid metabolism, and for the past two years a Diabetes UK clinical champion, says that in 2014 there were 42 insulin incidents at the trust relating to wrong dose, failure to prescribe, or wrong insulin. “Care was disjointed,” he says.

In an 850 bed trust where many patients with diabetes were admitted for other reasons, keeping track is difficult. “We instituted a daily hypo alert, sent by email to me and two specialist nurses, so we know exactly where patients with low blood sugar readings are. We go there, advise staff, and can see if the problem is repeated.”

Other changes involved pre-prescribing insulin units to reduce prescription errors, an easy to follow protocol for treating diabetic ketoacidosis (DKA), regular training for ward staff and incoming junior doctors, a “Think Glucose” champion in every ward, a mandatory hypo box in the resus trolley in every ward, and introducing diabetes accreditation for wards meeting pre-set criteria.

“Work is by no means complete, but things have changed quite a lot,” De says. Insulin incidents are down, treatment of DKA patients is quicker, and junior doctors are more confident. The interventions were simple, so costs were minimal.

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