Patient safety and diabetes

As safety investigators, we often see how risks rarely sit within one part of the healthcare system. Instead, they emerge across boundaries – between services, organisations and the environments in which care is delivered. This is particularly evident in our work exploring insulin safety.

Across three recent reports that look at supporting safe insulin administration in vulnerable groups in the community (two reports) and supporting safe insulin administration in inpatient settings, a consistent picture is emerging. While the care settings differ, many underlying challenges are similar.

A shared challenge across care settings

Insulin is a high-risk medicine. Its safe use depends not only on clinical knowledge, but on communication, coordination and an accurate understanding of a person’s needs and capabilities.

In the community investigations, we heard how vulnerable patients – including those with cognitive impairment, frailty or complex social circumstances – often fall between services. Self-administration of insulin requires a level of capability, and the support needed to develop this may not always be present.

In some cases, we found there was limited clarity about who is responsible for reviewing a patient’s ability to safely self-administer insulin, particularly when care is shared between primary care, community teams and family or informal carers.

In inpatient settings, we heard about competing priorities, workforce constraints and how variable training can impact the safe delivery of insulin. Systems designed to support safe medication administration may not always align with the realities of the hospital ward.

Recognising vulnerability and changing needs

A person’s ability to self-administer insulin may change over time due to illness, cognitive decline, or changes in their social support. However, systems do not always adapt quickly enough to reflect these changes.

This can result in people continuing to self-administer when it is no longer safe, or losing independence where appropriate support could enable them to continue safely.

Recognising and responding to these shifts requires regular assessment of capability, clear triggers for review when circumstances change and stronger coordination between health and social care.

Bridging the gap between community and hospital care

Patients admitted to hospital may arrive with limited information about their insulin regimen or level of independence. Similarly, discharge processes do not always ensure community teams, carers or patients themselves are fully informed and supported.

This can lead to delays in insulin administration, loss of established routines that support safe self-management and increased reliance on staff who may not be familiar with the individual’s needs.

Improving these transitions between care providers and support networks is critical to reducing harm.

The importance of a system-wide response

What links the findings from these reports is not a lack of commitment to insulin safety from patients, NHS staff or carers, it’s the complexity of the systems they operate within.

Across all three reports, we identified these challenges that require a system-wide response:

• Gaps in information flow – critical information about insulin regimens, patient capability or recent changes is not always transferred effectively between settings.
• Variation in training and competency – staff confidence and capability in insulin management can differ significantly, particularly outside specialist teams.
• Unclear responsibility for risk – it is not always clear who should assess and maintain safe insulin use when several services are involved.
• Limited system-wide oversight – organisations often manage risk within their own boundaries, without visibility of the wider patient journey.

What needs to change?

While each of our reports includes specific safety observations and recommendations, there are some clear cross-cutting priorities:

• Strengthen communication across the system to ensure accurate, timely information follows the patient.
• Clarify accountability to define who is responsible for assessing and supporting safe insulin throughout a person's care.
• Invest in training and support to build confidence and competence beyond specialist teams.
• Design systems around the patient journey rather than organisational boundaries.

These are not quick fixes. They require collaboration across services, professions and organisations.

Taken together, these reports highlight the importance of viewing insulin safety as a whole-system issue. Improving safety depends on our ability to connect the insights from different care settings and act on them collectively. By doing so, we can better support both patients and NHS staff in managing one of the most commonly used – and highest risk – medicines in healthcare.

We plan to publish two further reports in the near future, that look at insulin administration in relation to people with learning disabilities, and technology.

In the meantime, I would encourage you to read the full investigation reports to explore our findings and safety learning in more detail:

• Insulin: supporting safe self-administration for patients in the community with a mental health problem
• Insulin: supporting safe self-administration for patients in the community with a disability
• Insulin: supporting safe administration in inpatient settings