From a staff perspective, a patient experiencing a mental health problem with access to insulin was described as a “huge red flag”.

In this case, the patient’s emergency readmission after not taking his insulin shows the real potential for harm when these systems don’t work as intended.

She had insulin-treated type 2 diabetes and required high-dose insulin (500 units per ml) from an insulin pen device.

A patient who had recently been discharged from hospital was administered insulin by a community nurse.

These bundles include flush fluid and insulin.

We’re also working on investigations that aim to improve the safety of insulin administration in both community and inpatient settings.

This national learning report analyses the findings of the investigations previously carried out by HSIB concerning incidents classified as never events.

Vignette A A patient who had recently been discharged from hospital was administered insulin by a community nurse.