Download Diabetes training to target errors over insulin dosages

Around one million people in the UK \on insulin
injections to control levels of glucose
Statistics show there have been 3,931 serious
incidents involving insulin since 2001.
Officials say the actual figure may be much higher
as many incidents go unrecorded.
Moira Pullar, 62, died at Monklands General
hospital in January 2004, when she was given 10
times too much insulin by a nurse who misread her
poorly written diabetic records.
A, "U" or "IU". which can be misread as "0". In some
cases staff have misinterpreted "1 U" as 10 units –
10 times the required dose.
Higher than required doses of insulin can suddenly lead to
hypoglycaemia – too little glucose in the blood – which if left
untreated can lead to confusion, clumsiness or fainting.
Severe cases can cause seizures, coma or death.
About 21,000 doctors and nurses voluntarily registered for the
safety training programme, set up by the National Patient
Safety Agency and NHS Diabetes. But only 13,000 have
successfully completed the course, raising safety concerns
among patients groups.
Professor David Cousins of the NPSA said that insulin is
safely given to thousands of patients each day. "However,
there is a real potential for serious harm if it is not
administered and handled properly."
Hospitals and community health organisations have
ordered an online mass safety training programme
for doctors and nurses, after official figures revealed
that thousands of diabetes patients have been given
the wrong doses of insulin.
Around one million people in the UK with diabetes
rely on insulin injections to control levels of glucose
in their blood. In statistics show there have been
3,931 serious incidents involving insulin across the
UK since 2001. Officials say the actual figure may
be much higher as many incidents go unrecorded.
Higher than required doses of insulin can suddenly lead to
hypoglycaemia – too little glucose in the blood – which if left
untreated can lead to confusion, clumsiness or fainting.
Severe cases can cause seizures, coma or death.
About 21,000 doctors and nurses voluntarily registered for the
safety training programme, set up by the National Patient
Safety Agency and NHS Diabetes. But only 13,000 have
successfully completed the course, raising safety concerns
among patients groups.
Professor David Cousins of the NPSA said that insulin is
safely given to thousands of patients each day. "However,
there is a real potential for serious harm if it is not
administered and handled properly."
Moira Pullar, 62, died at Monklands General
hospital in January 2004, when she was given 10
times too much insulin by a nurse who misread her
poorly written diabetic records.
The NPSA, which collects data on drug errors, has
issued new guidelines stressing that the term "units"
must be used in all contexts and staff must never use
the abbreviations, "U" or "IU". which can be misread
as "0". In some cases staff have misinterpreted "1 U"
as 10 units – 10 times the required dose.
Diabetes training to target errors over insulin dosages
Safety course ordered for doctors and nurses after official
figures reveal thousands of mistakes
The Observer, Sunday 19 December 2010
Hospitals and community health organisations have ordered
an online mass safety training programme for doctors and
nurses, after official figures revealed that thousands of
diabetes patients have been given the wrong doses of insulin.
Around one million people in the UK with diabetes rely on
insulin injections to control levels of glucose in their blood. In
most cases they monitor their own blood and adjust the dose
appropriately, but the very elderly or very young, or those with
other medical complications, have to rely on doctors and
nurses to do the prescribing, monitoring and administration.
NHS statistics show there have been 3,931 serious incidents
involving insulin across the UK since 2001. Officials say the
actual figure may be much higher as many incidents go
unrecorded.
Higher than required doses of insulin can suddenly lead to
hypoglycaemia – too little glucose in the blood – which if left
untreated can lead to confusion, clumsiness or fainting.
Severe cases can cause seizures, coma or death.
About 21,000 doctors and nurses voluntarily registered for the
safety training programme, set up by the National Patient
Safety Agency and NHS Diabetes. But only 13,000 have
successfully completed the course, raising safety concerns
among patients groups.
Professor David Cousins of the NPSA said that insulin is
safely given to thousands of patients each day. "However,
there is a real potential for serious harm if it is not
administered and handled properly."
He urged staff to take the course. "This guidance is essential
as the effects of wrong dosage can lead to catastrophic
consequences.“ The health charity Diabetes UK welcomed
the initiative but was concerned as to why so few doctors and
nurses had completed the course. Cathy Moulton, a nurse
with expertise in diabetes who is one of the charity's clinical
advisers, said that given the potential for death or serious
harm, many hospitals are making the training mandatory.
"Many of these shocking errors are avoidable with, for
example, the right training, systems and protocols in place.
Diabetes specialist teams should be in place to provide
training, expertise and support to non-diabetes specialists."
In January 2005, Sybil Jones, 79, from Poole in Dorset died
as a result of an overdose of insulin. An agency nurse failed to
monitor her sugar levels properly. Moira Pullar, 62, died at
Monklands General hospital in January 2004, when she was
given 10 times too much insulin by a nurse who misread her
poorly written diabetic records.
The NPSA, which collects data on drug errors, has issued
new guidelines stressing that the term "units" must be used in
all contexts and staff must never use the abbreviations, "U" or
"IU". which can be misread as "0". In some cases staff have
misinterpreted "1 U" as 10 units – 10 times the required dose.
The NPSA also says that NHS organisations must ensure that
all insulin doses are measured and administered using an
insulin syringe or pen device and never using intravenous
syringes. Moulton said: "It is puzzling that up until last week
around 8,000 healthcare professionals registered for the
online training programme in the safe use of insulin had yet to
complete it. This commitment must be taken seriously to help
ensure the safety of people with diabetes, and so we welcome
the news that many trusts are making this training mandatory.“
Fraser Wood the director of communications at NHS Diabetes
said: "It's hoped the campaign will lead to greater awareness
of the potential dangers of poor prescribing."
Diabetes training to target errors over insulin dosages
Safety course ordered for doctors and nurses after official figures reveal thousands of
mistakes
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Mark Gould
The Observer, Sunday 19 December 2010
Article history
A diabetes sufferer injects himself with insulin. Photograph: Corbis
Hospitals and community health organisations have ordered an online mass safety training
programme for doctors and nurses, after official figures revealed that thousands of diabetes
patients have been given the wrong doses of insulin.
Around one million people in the UK with diabetes rely on insulin injections to control levels of
glucose in their blood. In most cases they monitor their own blood and adjust the dose
appropriately, but the very elderly or very young, or those with other medical complications,
have to rely on doctors and nurses to do the prescribing, monitoring and administration.
NHS statistics show there have been 3,931 serious incidents involving insulin across the UK
since 2001. Officials say the actual figure may be much higher as many incidents go
unrecorded.
Higher than required doses of insulin can suddenly lead to hypoglycaemia – too little glucose
in the blood – which if left untreated can lead to confusion, clumsiness or fainting. Severe
cases can cause seizures, coma or death.
About 21,000 doctors and nurses voluntarily registered for the safety training programme, set
up by the National Patient Safety Agency and NHS Diabetes. But only 13,000 have
successfully completed the course, raising safety concerns among patients groups.
Professor David Cousins of the NPSA said that insulin is safely given to thousands of patients
each day. "However, there is a real potential for serious harm if it is not administered and
handled properly."
harm if it is not administered and handled properly."
He urged staff to take the course. "This guidance is essential as the effects of wrong dosage
can lead to catastrophic consequences."
The health charity Diabetes UK welcomed the initiative but was concerned as to why so few
doctors and nurses had completed the course. Cathy Moulton, a nurse with expertise in
diabetes who is one of the charity's clinical advisers, said that given the potential for death or
serious harm, many hospitals are making the training mandatory. "Many of these shocking
errors are avoidable with, for example, the right training, systems and protocols in place.
Diabetes specialist teams should be in place to provide training, expertise and support to nondiabetes specialists."
In January 2005, Sybil Jones, 79, from Poole in Dorset died as a result of an overdose of
insulin. An agency nurse failed to monitor her sugar levels properly. Moira Pullar, 62, died at
Monklands General hospital in January 2004, when she was given 10 times too much insulin
by a nurse who misread her poorly written diabetic records.
The NPSA, which collects data on drug errors, has issued new guidelines stressing that the
term "units" must be used in all contexts and staff must never use the abbreviations, "U" or
"IU". which can be misread as "0". In some cases staff have misinterpreted "1 U" as 10 units
– 10 times the required dose.
The NPSA also says that NHS organisations must ensure that all insulin doses are measured
and administered using an insulin syringe or pen device and never using intravenous
syringes.
Moulton said: "It is puzzling that up until last week around 8,000 healthcare professionals
registered for the online training programme in the safe use of insulin had yet to complete it.
This commitment must be taken seriously to help ensure the safety of people with diabetes,
and so we welcome the news that many trusts are making this training mandatory."
Fraser Wood the director of communications at NHS Diabetes said: "It's hoped the campaign
will lead to greater awareness of the potential dangers of poor prescribing."