Making insulin treatment safer. A novel approach to workplace assessment in foundation education Dr. Ciara Lee for the MITS Team: Rosemary Donnelly, Angela Carrington, Angela Carragher, Deborah Millar and Prof. Tim Dornan

NDIA and EQUIP EQUIP Study 2009 - Two thirds of inpatient prescriptions are written by FDs 43% of prescription charts for patients with type 1 diabetes have errors. EQUIP: FDs’ most serious errors are with insulin. Insulin is daunting!

EQUIP ‘...learning to prescribe is a dynamic series of socially negotiated interactions within and between individuals, communities, and environments.’

What is MITS? Aim to improve experiences of: Patients on insulin in hospitals Foundation doctors

How we have implemented MITS MITS Case Based Discussion Trained “MITS Debriefers”: 22 Pharmacists, 25 Doctors, 10 Nurses and 2 service users Offered to all FDs in Northern Ireland NIMDTA approved TURAS ePortfolio sign-off

MITS CBD Opportunity to talk about an insulin prescribing experience Helping to provide FDs with the skills to navigate complexity and uncertainty FD makes a written commitment to change Skills transferable to other scenarios

MITS CBD - an example Case Details: FY1 covering acute medical admissions ward. Asked to prescribe morning dose of insulin for 65yo T2DM admitted with LRTI the previous night. Patient had not been taking insulin at home and FY1 was concerned about prescribing the pre-admission dose.

In what aspects of SMAC2 will you change your behaviour In what aspects of SMAC2 will you change your behaviour? How will you do this? Prescribing at the bedside where possible, especially new patients. Have the confidence to flag up issues with seniors on the ward round Use ward pharmacist as a resource Be quicker to seek specialist diabetes review in complex cases

What might make you unsuccessful? How will you prevent that? Unfamiliar with ward/patient, other staff not approachable How will you prevent that? Have the confidence to speak up anyway When on a new ward, take time to introduce myself to staff Prescribe at the bedside where possible

Overall what have you learned about prescribing insulin well? Seeing patient as a whole, getting their story Being able to recognise and speak up when help is needed with a prescribing decision Reviewing whole insulin regime rather than a single dose

What next? 68 MITS CBDs completed to date. Feedback from FDs themselves is very positive Continue to pilot the concept of service users conducting CBDs to share expertise in T1DM Increase the engagement of nurses and pharmacists in Foundation training SMAC2 already being transferred to other high risk medications

MITS Proof of Concept Detailed qualitative analysis of 53 CBDs Treating sick, complex patients without support provoked uncertainty Prescribing sometimes viewed as a menial task to be done quickly without assessing patients Debriefers empowered 53 FDs to make 307 statements, committing themselves to learn better practice

Any Questions? Contact: clee19@qub.ac.uk www.med.qub.ac.uk/mits

References Dornan T et al (2009) An in depth investigation into causes of prescribing errors by foundation trainees in relation to their medical education. EQUIP study. London: General Medical Council; 2009. Supporting Safe Prescribing: Royal College of Physicians 2017: https://www.rcplondon.ac.uk/projects/outputs/supporting-junior-doctors-safe-prescribing HSCIC. National Diabetes Inpatient Audit. 2013.