1. Insulin Prescribing

2. Learning outcomes By the end of the session you will be able to:
Explain the errors commonly associated with insulin prescribing
Outline the recommendations made by the NPSA alert on the safer use of insulin
Describe the steps you can put in place to make insulin prescribing safer
Demonstrate that you can review a prescription for insulin to identify any errors

3. Insulin facts 1 in 5 patients on an inpatient ward has diabetes
Around 4 in 10 inpatients with diabetes experience a medication error
Since 2003 insulin errors have led to over 17,000 safety incidents including 6 deaths
Report showed that 62% insulin errors were around administration and prescribing
And, most importantly,
Insulin safety training is now a requirement for all those who prescribe, prepare, handle or administer insulin.

4. What do you know about insulin already?
Get students to shout out – correct any miunderstandings

5. So, what goes wrong?

6. Task
In groups of three or four make a list of the things you think can go wrong when prescribing and / or administering insulin.

7. Press images

8. The 4 R’s
Right insulin
Right time
Right dose
Right way
From the NPSA

9. Right Insulin
Over 20 insulins on the UK market

10. The right insulin – the problem
Insulins have a proprietary name e.g. Lantus® and an approved name e.g. Insulin glargine.
Insulins are known by their brand name.

11. The right insulin – the problem
Sometimes the name is in two parts e.g. Novomix® 30. This is a mixture of 30% fast-acting and 70% longer-acting insulin. The ‘30’ is a vital part of the name and is not the dose.

12. What can you do to make sure the right drug is prescribed?
Guidance
Check the name of the insulin with the patient.
Check the name in the British National Formulary (BNF).
The BNF is the official source of information about prescribing insulins.
State brand name when prescribing e.g. Lantus

13. The right dose – the problem
100 units per ml
UK insulin for people is made in one strength – 100 units per ml also called U100 insulin. This is not the dose!

14. The right dose – the problem
Units
Insulin doses are measured in units
Units can be abbreviated to u or iu
Write on a board to demonstrate

15. The right dose – the problem
However 4 units written as 4u could become 40 units, or 4iu could become 410 units with fatal results!

16. The right dose – the problem
Get the dose right
The dose is crucial. People with diabetes – children, adults, underweight, overweight, ill, well, need very different doses. 5 units can make one person unconscious but make virtually no difference to the glucose in another.

17. The right dose – the problem
People with diabetes may adjust the dose of fast-acting insulin according to what they are eating, their blood glucose or exercise.

18. What can you do to make sure the right dose is prescribed?
Never abbreviate “units” – always write it out in full e.g. 4 units
Let patients adjust their own dose if possible – they will usually be better at it than you.
Check the dose with the chart and the patient.

19. 4 main types of insulin Rapid acting Short acting Intermediate acting
Long acting

20. The right time Understand the release profiles of insulins
Check with the patient which insulin is given and when.
Is it taken with food or at bedtime?

21. The right time
Rapid-acting insulin starts to work in minutes and brings the glucose down in 2 to 4 hours.
Modern analogue insulins can be given immediately before or straight after food.
Fast-acting insulins can also be used to bring down a high glucose level – take care not to cause hypoglycaemia.
Longer acting insulins are used for background action or to work later in the day. Their effects may last for days. Some of these insulins can be given without food because they work so slowly e.g. Lantus®, Levemir® .
Understanding release profiles can help you to decide which insulin is given when

22. The right time Type Onset Time to peak action Duration of action Rapid
Humalog
Novorapid
Apidra
5 – 15 mins
30 – 90 mins
3-5 hours
Short
Actrapid
Humulin S
Insuman Rapid
30 – 60 mins
2 – 3 hours
5-8 hours
Intermediate
Insulatard
Humulin I
Insuman basal
2 – 4 hours
4 – 10 hours
10 – 16 hours
Long acting
Levemir
Lantus
20 – 24 hours
For insulin detemir, the duration of action is dose-dependent: around 12 hours for 0.2 units/kg dose and 20 hours for 0.4 units/kg dose. Consequently, at lower doses, insulin detemir may need to be given twice daily.

23. Common regimes Once daily – long acting Twice daily – mix
Basal bolus – given four time a day to mimic normal physiology. Sort acting with meals PLUS intermediate once a day
IV insulin infusion “sliding scale” used in hospital

24. The right way Insulin comes in the following containers/devices: Vials
Cartridges for insulin pens
Preloaded insulin pens
Insulin pump systems
If insulin is given intramuscularly it works very quickly and can cause rapid hypoglycaemia. The effect is even faster intravenously and insulin is usually infused slowly rather than given as a bolus.
Take some examples of vials, cartridges, pre-loaded pens
Insulin is usually injected subcutaneously so insulin needles are short. The subcutaneous dose is either injected all at once (bolus) or as a continuous infusion (insulin pump).

25. What can you do to make sure the insulin is administered in the right way?
Only give insulin in a syringe, pen or pump designed solely for insulin. Never use any other syringe or device. Prescribe the correct device for the patient.
Prescribe the correct route – usually SC
Patients on insulin usually know how to inject their own insulin – listen to the patient. In most cases, unless they are too ill or confused, the patient is the best person to inject their own insulin.

26. When would you use a
sliding scale?

27. Sliding scale Syringe of dextrose PLUS Actrapid®
Mainly used in the peri-operative period to tightly control CBG
If the patient is NBM
CBGs must be checked hourly and the rate will be dependent on the CBGs

28. Prescription review Look at the prescription we have give you.
Highlight any errors you find – how would you rectify these?
Explain the importance of prescription review skills for medics.

29. Objectives revisited:
Explain the errors commonly associated with insulin prescribing
Outline the recommendations made by the NPSA alert on the safer use of insulin
Describe the steps you can put in place to make insulin prescribing safer
Demonstrate that you can review a prescription for insulin to identify errors