Insulin: supporting safe administration in inpatient settings

This investigation focuses on the safety of patients in hospital in England who have diabetes requiring treatment with insulin. It considers issues around the management of diabetes care and the safe administration of insulin for inpatients. Insulin is a high-risk medication and is among the most common causes of harm from medication errors in the NHS.

The prevalence of diabetes in England is rising, with an estimated 4.2 million people affected by 2030. Diabetes affects a growing proportion of the inpatient population and is associated with significant risks when care is not managed effectively.

Going into hospital can create risks for patients with diabetes. Patients have come to harm or died in hospital because their diabetes requiring treatment with insulin has not been appropriately managed.

Hearing and reviewing the experiences of those affected led the investigation to examine the following in relation to the patient safety issue:

• How staff are supported to monitor and care for patients with known diabetes on a hospital ward.
• How patients are supported to safely self-administer their insulin (through injections or via a pump or hybrid closed loop system), as part of a diabetes self-management regime.
• What national recommendations/observations have been made to date and the outcomes seen.
• The investigation’s findings are offered to support improvements in services for patients who are admitted to hospital and require ongoing care for their diabetes that requires insulin therapy.

• Integrated care board (ICB), regional and national oversight for inpatient diabetes care is fragmented, and assurance for patient safety is devolved to individual trusts. This leads to gaps in responsibility and accountability for implementing national guidance and recommendations, and for acting on national audit data, for improvement of patient safety.
• Regulatory activity requires strengthening to effectively assess and address safety concerns relating to inpatient diabetes care.
• Local hospital oversight structures required by national guidance and recommendations, such as diabetes safety boards, are often absent. This can hamper local-level oversight and mitigation of risks, increasing risks to inpatients who have diabetes.
• Prioritisation and funding of inpatient diabetes care at the hospital and ICB level has not supported the full implementation of national guidance and recommendations.
• Participation in the National Diabetes Inpatient Safety Audit is low, limiting the ability to track trends, benchmark performance, or drive strategic and nationwide diabetes care improvements.
• Most inpatient diabetes care is delivered by non-specialists who may lack confidence and/or competence in diabetes management.
• Specialist diabetes teams are often under-resourced and unable to provide 7-day coverage to support non-specialist staff and care for patients. Even at recommended staffing levels, specialist teams cannot always see every patient who may need support.
• Diabetes/insulin awareness training for non-specialist staff and students is inconsistent. Education gaps persist at both trust and undergraduate levels, with no national minimum mandated standard for diabetes care or insulin safety education, training and competency assessments.
• Many hospital clinicians, along with national stakeholders, strongly support adding blood glucose levels to the National Early Warning Score (NEWS2) to improve the detection of diabetes-related patient deterioration, but acknowledge challenges in doing so.
• Many patients who safely self-administer insulin at home through injection, insulin pumps, or hybrid closed loop systems, are prevented from doing so in hospital. This can be due to local policies on diabetes self-management and insulin self-administration, and the reluctance of staff to allow patients to self-administer because they fear being blamed if things go wrong.
• Lack of clarity about safe bedside storage of insulin and misconceptions about the regulatory stance on this create barriers for patients to self-administer.
• Networked glucose meters can improve safety, but implementation of required hardware and software is inconsistent.
• There is limited integration between hospital networked glucose meters and electronic patient records, creating potential blind spots in inpatient diabetes care.

Safety learning for integrated care boards

HSSIB suggests that integrated care boards consider the findings of this report to inform funding prioritisation decisions for trust diabetes specialist inpatient services. This is to help support the delivery of safe inpatient diabetes care through appropriately staffed 7-day inpatient diabetes specialist services to mitigate patient harm.

Safety learning for NHS trusts

HSSIB has developed the following prompts to support local-level learning for NHS trusts.

Self-management of diabetes and insulin administration

• Do you have a policy that supports patients to safely self-manage their diabetes and support self-administration of insulin?
• Is your policy clear, available, and does it enable clinicians to support safe self-management and self-administration?
• Are the timing and content of meals considered in support of patients self-managing their diabetes?
• Is safe bedside storage of insulin provided to support self-administration? If not, how could this be supported?
• Are clinicians aware of national guidance and the regulatory stance regarding promotion of safe self-management of diabetes and insulin administration?

Diabetes specialist workforce and capacity

• Is your inpatient diabetes specialist team appropriately resourced to help mitigate known diabetes-related risks?
• Is your diabetes inpatient specialist team supported to operate out of hours, such as over weekends and bank holidays?

Non-specialist diabetes care

• Do you protect education and training time for diabetes training?
• Does your diabetes training ensure key risks to inpatients with diabetes are highlighted to staff?
• Do you have a diabetes specialist team that is appropriately resourced with sufficient capacity to deliver diabetes education and training?

Hospital diabetes technology

• Do you have networked glucose meters to support remote monitoring of patients with diabetes?
• Do the glucose meters in your hospital automatically upload data to electronic patient records, and does this support remote monitoring of patients? Does your inpatient diabetes specialist team access diabetes related reports/alerts daily to identify patients at risk?
• Do you provide digital tools or apps to support your non-specialist clinicians in providing safe diabetes care?

Wearable diabetes technology

• Do you have a wearable diabetes technology element in your diabetes education and training programme?
• Do you have clear and available guidance on wearable diabetes technology for your non-specialist clinicians?

Oversight and governance

• Do you participate in the Diabetes Care Accreditation Programme (DCAP)?
• Do you submit data to the National Diabetes Inpatient Safety Audit (to be superseded by the National Diabetes Audit for Inpatient Care)?
• Do you have a diabetes safety board with senior management involvement?
• Does your diabetes safety board work with your inpatient diabetes specialist team to understand key diabetes risks and issues?
• Does your diabetes safety board have the authority to agree actions and prioritise resources for their implementation?