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:

Safer administration of insulin - an opportunity missed

Lamont et al have highlighted the concerns re safer prescribing of
insulin. Whereas they have highlighted some key areas, an opportunity to
go a step further has been missed.

In a busy acute setting, many a times the on call medical registrar
has to give instructions over the telephone to other doctors or nurses,
pending a formal review. Responding from a busy and noisy A/E department
over the phone, 'fifteen units' of actrapid insulin can be easily
'interpreted' or 'misheard' as 'fifty units of actrapid insulin' and could
be accordingly prescribed. The consequences of this could be catastrophic
and patient could suffer irreversible brain damage if undetected.

We suggest insulin dose prescribing should always be written in words
and not in figures. The nursing staff should be advised not to administer
insulin unless written in words.

Mona Arora, GP Research Facilitator, Keele University, ST5 3SY

Amit Arora, Consultant Physician, University Hospital of North
Staffordshire, Stoke on Trent, ST4 6QG


Competing interests: No competing interests

01 November 2010
Mona Arora
General Practitioner
Amit Arora, Consultant Physician, University Hospital of North Staffordshire
GP Research Facilitator, Keele University