Insulin: administration of insulin at the right dose and right time in inpatient settings

We have launched an investigation to examine risks to patient safety when patients who take insulin are admitted to acute hospitals.

We have also launched a separate investigation that explores risks to patient safety for patients in the community who self-administer long-term insulin and who may be at increased risk of harm because of their circumstances.

Diabetes is one of the most common chronic diseases in England and the number of people with the condition is on the increase. It is a condition where blood glucose levels are too high due to various factors, including problems with the pancreas (which produces insulin). People with diabetes require their blood glucose levels to be monitored and to be maintained within a specified range. Where blood glucose levels are not maintained adequately, short-term and long-term problems can arise for the person which can be life-threatening.

In many people, management of diabetes involves the administration of insulin. Insulin can be administered in various ways including via a needle and syringe, pen device or pump.

Issues associated with medications that patients take long-term are a recognised risk to patient safety. We identified the focus for these investigations after reviewing the following evidence sources:

• previous HSSIB investigations and insights received
• national serious incident reporting system
• reports to prevent future deaths issued by HM Coroners
• academic and policy literature.

We also engaged with various stakeholders to seek their insights in relation to the risks to patient safety associated with long-term administration of insulin. These stakeholders include representatives from national bodies involved in medication and patient safety across primary, community and secondary care.

Evidence suggests that several care processes are associated with insulin-related incidents in acute hospital settings. The investigation will explore:

• Reconciliation and prescribing of insulin: where it is not recognised that the patient takes insulin, it is not prescribed, or it is prescribed incorrectly.
• Administration of insulin: where the wrong preparation/dose is administered or it is administered at the wrong time, or where the patient is not supported to self-administer.
• Monitoring of insulin: where blood glucose levels are not monitored and treatment is not adapted to meet a patient’s needs when they are unwell.
• Perioperative insulin management: where insulin is omitted or not managed during surgical operations.

We expect to publish the investigation report in March 2026.

We are keen to hear from anybody with an interest in this subject matter. This includes patients, families, carers and health and care professionals who may wish to share their experience. If you would like to speak to us about this investigation before we publish the report, please email enquiries@hssib.org.uk.