What is it about?

Administering insulin to a patient is perceived as a simple intervention. However without clear processes in place and very straightforward documentation this simple intervention can easily lead to avoidable errors and potential harm to patients. Using a recognised Quality Improvement tool to inform changes we have shown that errors can be reduced and sustained.

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Why is it important?

The work is important because reducing insulin errors is in the best interest of both patients and staff. The use of a recognised Quality Improvement tool has allowed change to made at pace whilst maintaining patient and staff safety. The work demonstrates the importance of making no assumptions about why errors have occurred in the past, and the importance of truly listening to staff who carry out the administration of insulin on a daily basis as they will be able to help shape relevant changes.


I hope that anyone reading the article will be able to take something from it and use in their place of work. the methods employed can be used in a range of scenarios where quality is a concern. Reducing errors in relation to insulin, or indeed any medication, is in the interests of patients but also the wider interests of clinical staff and healthcare providers. Correcting errors is costly in time, reputation and money. Reducing errors allows for valuable resources to be directed and utilised better.

David Leeson
Leicestershire Primary Healthcare Trust

Read the Original

This page is a summary of: Creating sustained and positive changes to patient safety: reducing insulin administration errors in a district nursing service, British Journal of Community Nursing, March 2022, Mark Allen Group,
DOI: 10.12968/bjcn.2022.27.3.122.
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