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

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

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

Later this year we will publish a report about safe self-administration of insulin for people with a learning disability.

Mike’s son told the investigation that his dad had type 2 diabetes mellitus (where the body does not produce enough insulin, or the body's cells do not react to insulin properly) and had some ongoing health...

The list was: antimicrobials (antibiotics, antivirals, antifungals) anticoagulants antiepileptics cardiac medication corticosteroids clozapine desmopressin diabetic medication (oral agents and insulin)...

While he was in hospital the medication for managing his diabetes was changed and he was started on insulin.

Over the next 11 days, the patient was seen regularly by the diabetes nurse specialist and adjustments were made to his insulin medication to try to stabilise his blood glucose levels.

A staff member approached the nurses’ station with a separate drug chart for a patient taking insulin.

...vasopressors (to help manage blood pressure) atropine (to help manage slow heart rate) glucagon (which increases the amount of calcium available to the system and strengthens heart contractions) high-dose insulin...