Approximately 3.2 million people have diabetes and it is estimated that 20-30% of these are treated with insulin. Insulin is one of the top five high-risk medications worldwide, and errors can lead to patient harm. (1) In 2010 the NPSA reported that 61% of the 2003-2009 reports were related to administration of insulin and that inaccurate prescribing is the commonest issue relating to error.(2)
There are now over 30 different insulins available in the UK, several new insulin products have been launched in recent years, including high-strength, fixed combination and biosimilar insulins.
The MHRA Drug Safety Alert (2015) (3) on the newer insulins prompted Solihull Clinical Commissioning Group (CCG) to review prescribing processes within primary care. There was no existing guidance in place that addressed the specific needs of GP practices, so we decided to take a systematic approach towards reducing the risks of an error occurring.
Our aim was to improve the safety of insulin prescribing within primary care in Solihull by introducing risk reduction strategies at CCG level:
An 'Insulin Prescribing - Risk Assessment Tool' was developed collaboratively with diabetes specialists from other local NHS organisations. This was approved by the Birmingham, Solihull and Sandwell Area Prescribing Committee (BSSE APC) (APC) and was adopted by local acute trusts. (Appendix 1)
Using NICE Guidance KTT20(4) and the risk tool, Solihull CCG produced a policy outlining good practice for primary care, including consensus that encourages the use of insulin passports. (appendix 2). This also included an Insulin Guide Poster which can be displayed in clinic rooms detailing different insulin types. (Appendix 3)All new materials were emailed directly to the diabetes practice nurses and GPs through a CCG-held distribution list.
The Solihull CCG diabetes pharmacists have utilised different ways to improve awareness and understanding of insulin amongst primary care clinicians:
Education and training:
In Solihull – multidisciplinary team (MDTs)meetings are at every GP practice usually every 3-4 months, where diabetes patients are discussed, and a treatment plan implemented. The Diabetes MDT consists of a consultant diabetologist, DSN, dietitian, diabetes specialist pharmacist as well as a diabetes lead GP and practice nurse:
Monitoring outcomes and delivery:
The strategies implemented to date are ongoing. All policies and educational materials will be kept updated as new products become available. The CCG will be utilising its contacts within the PPG (Patient Participation Group) network, the patient panel and social media streams to encourage patients to ask for and carry their insulin passports. Usage of insulin passports will be audited in 6 months.
The main beneficiaries of the project are our patients; by putting all these strategies in place we are reducing the risks of patient harm – some of which could be severe. This may range from an acute hypoglycaemic event, an inadvertent change in device leading to patient confusion about how to administer their insulin, diabetic ketoacidosis, or to long-term poor control resulting from prescribing the incorrect insulin regime.
Examples of some of the errors that have been reported to the CCG in recent years include:
Our prescribers benefit as they have gained more knowledge around prescribing insulin safely, errors made would put them at risk of potential litigation.
The CCG is also a beneficiary as some of the errors could include the use of non-formulary insulins which are often more expensive than lower risk/formulary preparations- these are being reviewed within the practices. Also if the patient is continuing to receive two similar insulins on prescription, or if insulin is prescribed in error, this leads to drug wastage and unnecessary expenditure to the NHS.
It was important to make this issue a priority for the CCG as the diversity of available insulin products is growing and the risk of errors is increasing.
In the first year of this project we have implemented our objectives from the 'Insulin Prescribing - Risk Assessment Tool' for the GP/Practice nurses.
We have created different resources which have been approved by BSSE APC and are being used within the CCG to reduce the risks of Insulin Prescribing.
We have encouraged CPD and all the GP practices have been informed that they need to complete the SIX steps to insulin safety.
We have relaunched the use of Insulin Safety cards within the GP practices and this is due to be audited shortly.
Our searches within GP surgeries identifying errors such as two long acting insulins being prescribed on repeat etc… have led to prescriptions being amended and therefore safer prescribing for the patients.
We are helping to reduce risks by utilising our computer decision support tool and monitoring prescribing data. (Appendix 4).
The main area of prescribing we have focussed on initially is reducing generic prescribing of insulin glargine since Abasaglar was added to the formulary for all new insulin initiations. Comparing our baseline data April-Jun 2017 to the current quarter (an estimate as only 2 months data available- the average was taken for 3 months); this has reduced by approximately 70% (from 20 items to estimated -6 items).
Any GP practices who appeared in the results were highlighted to the Prescribing Support Pharmacists who have worked with the practices to review their prescribing. All of the patients with a generic glargine prescription were switched to the corresponding brand name to ensure continuity of supply and patient safety. We have now identified increased prescribing of generic insulin aspart and so will be working on this area of insulin prescribing too.
We are also monitoring the prescribing of non-formulary products. There was no prescribing of Humalog 200units/ml. Other non-formulary products; Xultophy and Tresiba 200 units/ml, the number of items has reduced by a third and a half respectively. (appendix 4)
Patients receiving Tresiba, Xultophy and Toujeo were also reviewed to check that these were intentionally prescribed and to ensure the practice's processes were safe. Non-formulary insulin prescribing was also highlighted; the patients involved were reviewed at the next consultant-led diabetes multidisciplinary team (MDT) 'virtual clinics'. Some of the patients had their treatment changed as a result.
Since the work undertaken in Solihull CCG, the Regional Medicines Optimisation Committee (RMOC) Midlands and East published guidance for formulary decision makers and insulin safety considerations (June 2018).(6) This guidance will be used to support insulin formulary submissions or amendments and further enhance the local work to improve safe prescribing.
