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:

Reducing insulin prescribing errors

We read with interest the safety report on behalf of the NPSA by
Lamont et al [1] highlighting a 19.5% national prescribing error rate for
insulin. We found an even higher error rate (38%) in our trust; but an
extensive training programme for doctors and other health professionals
better than halved our error rate to 16% [2].

We remain concerned, however, that rapid trainee turnover and
increasing dependence on shift work, make it difficult to give timely
feedback to prescribers. The reviewers suggest a national programme for
staff to help reduce prescribing errors. We propose a form of work-based
assessment (WBA) where the trainer invites the trainee to reflect on an
event. By making this a routine element of WBA, any stigma associated
with reflection on negative events might be lessened with trainees
encouraged to reflect on positive and negative episodes. Over time, these
assessments will not only inform progress made by the trainee in clinical
care, but also give a measure of the extent and effectiveness of their
critical reflective abilities.

Steven J McNulty

Consultant Diabetologist, St Helens and Knowsley NHS Trust, Merseyside L35

Andrew Lewis

Pharmacist, St Helens and Knowsley NHS Trust, Merseyside, L35 5DR

Kevin J Hardy

Consultant Diabetologist, St Helens and Knowsley NHS Trust, Merseyside L35

and Professor of Diabetes, John Moore's University, Liverpool

Competing interests: None declared.

1. BMJ 2010;341:c5269

2. Lewis AW, Bolton N, McNulty S. Reducing inappropriate abbreviations
and insulin prescribing errors through education. Diabetic Medicine

Competing interests: No competing interests

25 October 2010
Steven J McNulty
Consultant diabetologist
Andrew Lewis, Kevin Hardy
St Helens and Knowsley NHS Trust