Small changes make a big difference for safe diabetes care

Small changes can make a big difference when it comes to improving patient safety, says Jean MacLeod, a consultant physician with an interest in diabetes and Associate Medical Director for Patient Safety at North Tees and Hartlepool NHS Foundation Trust.

An average of 4.6% of the UK population are diagnosed as having diabetes. That’s 3 million people, and the number is projected to grow. But administering the main treatment – insulin – is complex, and studies such as the National Diabetes Inpatient Audit have reported high levels of insulin prescribing errors which could, in the worst-case scenario, lead to death.

‘Somehow, with insulin, there’s an acceptance of error within healthcare,’ says Jean MacLeod. ‘Some healthcare professionals still don’t have a good understanding of the different insulins, and because most patients manage their insulin outside the hospital, the scope for unreported prescribing errors is even higher.

To tackle this, in 2011 Jean helped set up the Regional Insulin Safety and Knowledge Project – a one-year initiative, part-funded by the Health Foundation, to increase insulin safety across the North East region, working with partners including Sunderland Royal Infirmary and the Royal Victoria Infirmary in Newcastle.

Enabling clearer communication

One area of focus was the notes written by hospital doctors when the patient was discharged. ‘Often, they would simply say “We increased the insulin dose”’, explains Jean. ‘For the GP reading these later, this was deeply unhelpful. They needed to know which insulin, which pen should be used to administer it, what dose, and how often.’ So, the project included a communications tool to describe different types of insulin consistently, to reduce error in written or verbal communication. This was accompanied by work to develop a region-wide prescription chart for inpatient insulin use, where formerly there had been different charts in each trust.

The team also developed a face-to-face training package, currently being rolled out to junior doctors, along with an educational poster highlighting a standard way of communicating insulin prescriptions.

A small-scale audit of doctors’ prescribing practices found a significant improvement after the posters had been displayed on the wards: a 57% increase in correct prescribing of insulin, a 20% improvement in the number that had the dose stated and a 15% increase in the number that specified how often the dose should be administered.

‘We’ve also seen less confusion among the district nursing teams and fewer queries from confused patients since the communications tool has been in place, and the community teams have proactively asked if they can use it,’ says Jean.

Jean was interested to find that the non-specialists tended to change their prescribing quicker than the specialist teams – particularly the consultants. ‘Perhaps we thought we were too clever to have to do this!’ says Jean. Jean’s dual role as project lead and medical consultant was a crucial factor in helping to win these colleagues round.

Crossing boundaries

The project was not only about medical practice: it involved the whole healthcare team. Because it focused on the entire pathway, a range of health professionals – including specialist nurses, practice nurses, GPs and junior doctors – were involved in developing the project. ‘In diabetes, we’re already used to working across care boundaries, so that was a great strength’, says Jean. The project also received support from funders, including Six Sigma training and help with data analysis.

The team is now keen to see the package adopted more widely. As Jean says, ‘If it’s working here, why not use it everywhere?’

Learning points

To Jean, the success of this project was highly influenced by its clinical roots. ‘If there’s a problem, clinicians are ideally placed to see the problems and can also work towards sustainable solutions,’ she says. Jean also strongly advocates recruiting a dedicated project manager to allow full-time clinicians to lead the project without being over-burdened.

But perhaps the biggest learning point was the simplicity of the solutions. ‘In hindsight, the changes we made were so straightforward: changing how we talk about insulin. But a small change can make a big difference across care boundaries,’ she says. ‘It’s just a matter of using the improvement methodology to make sure you identify the right thing to change.’