The National Patient Safety Agency received 3,881 wrong dose incident reports between August 2003 and August 2009. These included one death and one severe harm incident due to 10 fold dosing errors from abbreviating the word ‘unit’. National Patient Safety Agency Rapid Response Report Safer Administration of Insulin NPSA/2010/RR013 (PDF 59.2KB).

Original reporting of this information underpinned discussions across the North East Region regarding co-operative working to improve insulin safety under the auspices of the NESHA Safer Care programme and the Northern Region Diabetes Advisory Group. 

Four workstreams are responsible for taking the project RISK project forward. The workstreams will capitalise on the good work already evolving across the region, provide the forums for sharing outcomes and processes and provide the opportunity to learn from each other. 

Workstreams

1. Six Sigma - applying the six sigma methodology to look at care for people requiring insulin therapy where there is a transition across organisational boundaries. Lean Six Sigma Project Charter (PDF 19KB).
   
2. Insulin Charts - Standardise insulin prescribing across the North East region (e-prescribing/paper). Workstream Lead – Dr Raz Nayar. Workstream 2 Hospital Insulin Charts Project Initiation Document (PDF 68.6KB). 
   
3. Insulin Passports - Evaluating implementation of the roll-out of the National Insulin Passport across the North East Region. Workstream Lead – Sue Robson. Workstream 3 Insulin Passports Project Initiation Document (PDF70.3 KB).
   
4. Professional Training - Develop a standardised training package for professionals involved in insulin prescribing and administration. Workstream Lead – Dr Nicky Leech. Workstream 4 Professional Training Project Initiation Document (PDF 72.9KB).

For more details about the RISK Project see the above documents or the Project Initiation Document (PDF 95.5KB) and the RISK project flyer (PDF 500.3KB).