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Insulin Prescribing

Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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Page 1: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

Insulin Prescribing

Page 2: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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

Page 3: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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

Page 4: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

What do you know about insulin already?

Page 5: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

So, what goes wrong?

Page 6: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

Task• In groups of three or four make a list of

the things you think can go wrong when prescribing and / or administering insulin.

Page 7: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

Press images

Page 8: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

The 4 R’s• Right insulin • Right time• Right dose• Right way

Page 9: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

Right Insulin

Page 10: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

The right insulin – the problem

Page 11: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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.

Page 12: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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

Page 13: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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!

Page 14: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

The right dose – the problem• Units• Insulin doses are measured in units• Units can be abbreviated to u or iu

Page 15: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

The right dose – the problem

• However 4 units written as 4u could become 40 units, or 4iu could become 410 units with fatal results!

Page 16: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

The right dose – the problem• Get the dose right

Page 17: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

The right dose – the problem

Page 18: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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.

Page 19: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

4 main types of insulin

• Rapid acting• Short acting• Intermediate acting• Long acting

Page 20: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

The right time

Page 21: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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® .

Page 22: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

The right timeType Onset Time to

peak action

Duration of action

Rapid HumalogNovorapidApidra

5 – 15 mins 30 – 90 mins

3-5 hours

Short ActrapidHumulin SInsuman Rapid

30 – 60 mins

2 – 3 hours 5-8 hours

Intermediate InsulatardHumulin IInsuman basal

2 – 4 hours 4 – 10 hours

10 – 16 hours

Long acting LevemirLantus

2 – 4 hours 20 – 24 hours

Page 23: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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

Page 24: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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.

Page 25: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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.

Page 26: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

When would you use asliding scale?

Page 27: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

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

Page 28: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

Prescription review• Look at the prescription we have give you.

• Highlight any errors you find – how would you rectify these?

Page 29: Insulin Prescribing. Learning outcomes By the end of the session you will be able to: –Explain the errors commonly associated with insulin prescribing

• 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