The Australian Commission on Safety and Quality in Health Care will pilot a subcutaneous insulin chart beginning in August and September 2012. The pilot will determine the suitability and safety of a proposed subcutaneous insulin chart for national use. The work is being undertaken because of the large number of requests from health services to the Commission for a national subcutaneous insulin chart and because of the known risks from poor management of diabetics in acute care for intercurrent illness.
Expressions of interest will be sought from health services wishing to participate in the national pilot in July 2012. Health services interested in participating in the pilot can receive more information by contacting Ms Angela Wai on (02) 9126 3629 or by emailing mail@safetyandquailty.gov.au
The pilot will build on previous work by the Commission to identify a national subcutaneous insulin chart. In 2011 the Commission funded heuristic (human factors) analysis of 37 insulin charts developed and used by Australian health services. The resulting report, Task Analysis and Heuristic Analysis of Insulin Charts: Final report (PDF 5519 KB) prepared for the Australian Commission on Safety and Quality in Health Care, identified the Queensland Health subcutaneous insulin chart as representing best practice out of the charts reviewed.
The report recommended changes to the Queensland Health chart from a human factors perspective. These recommendations will be considered before national piloting commences. In addition, implementation, education and audit resources will be made available to support participating health services.
Background
Insulin is recognised internationally as a high risk drug accounting for approximately 15% of the highest risk incidents (actual and potential) in acute care. Errors in insulin prescribing and administration often occur as a result of unclear prescribing and unclear documentation of the dose administered, as well as the need to review multiple documents to administer an insulin dose and monitor its effect on a patient’s blood glucose level (BGL).
In addition to errors, the quality of insulin management is often sub-optimal due to the unfamiliarity of junior and infrequent insulin prescribers with insulin dosing and BGL management, and little experience of tailoring the dosing regimen to patient requirements. This may lead to poor blood glucose control and inappropriate responses to BGLs that are outside the limits set for notification of hypo and hyperglycaemia.