“Small changes can really make a big difference” says Helen Goodwin of Medway NHS Foundation Trust. Medway are tackling the High Risk Medications Intervention promoted by Patient Safety First. It is one of three interventions they are undertaking to reduce harm events occurring to patients, concentrating specifically on Insulin and trialling an amended prescription form in one ward.
“We are West Kent’s Vascular Centre so encounter many patients with diabetes who require vascular surgery. Insulin levels can sometimes be difficult to control after surgery so normal insulin regimes do change with varying dosages and different types of insulin prescribed. The change from intravenous sliding scale insulin during and immediately post surgery back to a sub-cutaneous route has resulted in patients suffering from hypoglycaemic and hyperglycaemic episodes. There were also a number of near misses with nurses’ mis-reading prescriptions, which were reported on our incident reporting forms. We realised that there were issues associated with the prescription and administration of insulin for diabetics.”
In Medway’s case, one of the problems was down to the design of the prescription form. Nurses usually take their direction on how much insulin to administer from hand written prescriptions made by doctors, made on a standard prescription sheet that’s uniform across the Trust. However as Medway have realised, there are risks to this process which have the potential to lead to an overdose. This is because the design has omitted to include a printed unit section where doctors note the dosage required. The risk is when the doctor abbreviates the international unit to IU and occasionally even to U, which in turn can be easily mistaken for a 0.
“In instances like this it is just too easy for the amount of insulin actually intended to be misread; resulting in a dose ten-fold that was intended. Errors here are nothing to do with competency or training but simply a case of misreading; a human error we all make.
“But the answer is so simple. We looked at the forms and eradicated the room for error by filling the unit box with pre-printed stickers with IU on, and there hasn’t been an error or near miss involving insulin on the reporting system since.”
Having tested the system on one ward, with the full support of the Consultant, the Head of Pharmacy and the Patient Safety lead, Medway are now preparing to roll this system out to other wards using the small step approach to change.
“We’ll now be trialling this amended form in other wards, starting slowly over a couple of days to make sure that no problems arise, and if we continue without an adverse incident then we’ll look at permanently altering the design of our prescription forms.”
Jacqueline McKenna, Directing of Nursing at Medway, says “We are committed to improving patient safety across the Trust and fully support Patient Safety First. This is one of several initiatives running across the Trust as part of our overall strategy for patient safety. Involving our front line staff is essential in making sure that any changes to systems do work in practice.”
Helen Goodwin also comments; “Feeling motivated and confident to test ideas that may benefit their patients has really helped staff feel involved in change and, crucially, to feel that they can go it alone making amendments that improve patient safety without feeling constrained – essential in creating a strong patient safety culture.”