High Risk Drugs: Insulin, errors, and strategies to minimize risks

LEARNING OUTCOMES

1. BACKGROUND: IDENTIFY HIGH RISK DRUGS (HRD)
2. BACKGROUND: HOW ERRORS IN INSULIN PRESCRIBING ARE REPORTED
3. BACKGROUND: HOW NHS ORGANISATIONS CONSIDER STRATEGIES FOR REDUCING THE ASSOCIATED RISK
4. WHY IS INSULIN A HIGH RISK DRUG
5. EXPLORE STATISTICS AND ALERTS FROM THE UK ON INSULIN SAFETY.
6. IDENTIFY COMMON PRESCRIBING AND ADMINISTRATION ERRORS ASSOCIATED WITH INSULIN.
7. RECOGNIZE PATIENT GROUPS AT HIGHER RISK OF INSULIN-RELATED ERRORS.
8. LEARN KEY STRATEGIES AND SYSTEM-LEVEL INTERVENTIONS TO MINIMIZE ERRORS.

DEFINITION OF HIGH-RISK DRUGS

WHAT IS A HIGH
RISK DRUG?
HIGH-RISK
MedicinesDifference between a
medicine's desired effect
(efficacy)
toxic dose
small1
and a lethal or
(potency) is very
Narrow
Therapeutic
Index
(NTI)

1. Blix HS, Viktil KK, Moger TA, Reikvam
   A. Drugs with narrow therapeutic index as
   indicators in the risk management of
   hospitalised patients. Pharm Pract
   (Granada) . 2010 Jan; 8(1) :50-5

HIGH RISK MEDICATIONS: A-PINCH ACRONYM

The acronym 'APINCH' is designed to serve as
a reminder that even routinely administered
medicines pose a high risk to patient safety.
Ausmed

• A
  ANTI-INFECTIVES
• P
  POTASSIUM AND OTHER ELECTROLYTES
• I
  INSULIN
• N
  NARCOTICS AND OTHER SEDATIVES
• C
  CHEMOTHERAPEUTIC AGENTS
• H
  HEPARIN AND OTHER ANTICOAGULANTS

IDENTIFYING HIGH RISK DRUGS

How do you know what is a HRD?
Acronyms e.g:
A-PINCH
Or a list form Guidelines like NPSA
+ your own knowledge
From 'High Risk Medications: 6 Errors You Don't Want to Make' at
https://www.ausmed.com/articles/high-risk-medications/

SOURCES OF HIGH RISK DRUG LISTS

. NHS body: National Patient Safety Alerts (NPSA) Now called
NatPSAs (National Patient Safety Alerts) produced by the
NaPSAC (The National Patient Safety Alerting Committee)
. NatPSAs sits under the body NHS Impact
. NPSA alerts from the old alert system still available and
relevant todayW
blood tests which are available from the Medicines Management office.

PATIENT SAFETY ALERTS AND GUIDANCE

Lithium Guidance

Patient Safety Alert
Lithium Record Booklet
Lithium Patient Information Booklet
Trust Guidance
Lithium - Blood Level Monitoring

Insulin Safety Alerts

Insulin
Rapid Response Alert - Safer Administration of Insulin: Recommendations to reduce the
administration errors of clinical staff which can be severe and even cause death:
Rapid Response Alert
E-learning recommended by the NPSA:
http://www.diabetes.nhs.uk/safe use of insulin/

Anticoagulant Safety Alerts

Anticoagulants
Warfarin & other anticoagulants
Patient Safety Alert - Actions that can make anticoagulant therapy safer: Helps staff manage the
risks associated with anticoagulants and reduce the risks of patients being harmed in the future.
Patient Safety Alert
E-learning recommended by the NPSA:
Starting patients on anticoagulants
Maintaining patients on anticoagulants
Work competences for anticoagulant therapy:
. Initiating anticoagulant therapy
. Maintaining oral anticoagulant therapy
· Managing anticoagulants in patients requiring dental surgery:
. Dispensing oral anticoagulants
.
Preparing and administering heparin therapy

Low Molecular Weight Heparins Alerts

Low Molecular
Weight Heparins
Alert: Reducing Treatment Dose Errors With Low Molecular Weight Heparins: Recommendations to
reduce the risk of under dosing which can lead to an increased risk of urther thromboembolic events, while
overdosing can increase the risk of bleeding.
Rapid Response Report

Omitted Doses Alerts

Omitted Doses
Rapid Response Alert - Reducing Harm From Omitted And Delayed Medicines In Hospital:
3SO HOW IS TH

INSULIN ADMINISTRATION GUIDELINES

21.2 Insulin
Errors in the administration of insulin are common and may cause severe harm or death.
In order to ensure that the correct dose is administered it is essential that where possible
insulin pen devices are used. If a syringe has to be used it should be an insulin syringe
marked in units and not mls. Intravenous syringes should never be used.
When prescriptions for insulin are written, prescribers should ensure that the word "unit" is
used and not "U" or "IU"
Insulin preparations are available in increasingly high strengths. Where these are available
in pen devices they are calibrated so that the correct dose is administered to the patient.
Insulin should never be withdrawn from these devices using a syringe.
Many patients are competent at managing their own insulin and many use carbohydrate
counting to adjust the dose that is administered. Every effort should be made to ensure that
patients are allowed to continue with this wherever possible. If it is felt that this is not
possible for reasons of patient safety there should be a discussion with the patient and/or
their family regarding the best solution to the management of insulin administration.
All patients should carry an insulin passport. This will normally be issued by the clinic where
the insulin is initiated, but they are available from pharmacy if it is discovered that the
patient does not have one.
Cutaneous amyloidosis at the injection site has been reported5 in patients using insulin and
this may affect glycaemic control. Remind patients to rotate injection sites within the same
body region.
Advice for healthcare professionals5:
· injection of insulin (all types) can lead to deposits of amyloid protein under the skin
(cutaneous amyloidosis) at the injection site
. cutaneous amyloidosis interferes with insulin absorption, and administration of
insulin at an affected site can affect glycaemic control
. remind patients to rotate injection sites within the same body region to reduce or
prevent the risk of cutaneous amyloidosis and other skin reactions (for example,
lipodystrophy)
. consider cutaneous amyloidosis as a differential diagnosis to lipodystrophy when a
patient presents with subcutaneous lumps at an insulin injection site
· advise patients:
o that insulin may not work very well if they inject into an affected 'lumpy' area
o to contact their doctor if they are currently injecting insulin into a 'lumpy' area
before changing injection site since a sudden change may result in
hypoglycaemia
0
to monitor carefully blood glucose after a change in injection site and that
dose adjustment of insulin or other antidiabetic medication may be needed
. report serious adverse drug reactions associated with insulin to the Yellow Card
Scheme
S TRUSTS?
HS trust
ocal formulary
cy on high risk
Approved by Medicines Management Group May 2021

USEFUL BODIES PRODUCING HIGH RISK DRUG RESOURCES

• SPS - Specialist Pharmacist Service - provides resources for
  patients who are on high risk drugs
• NRLS - National Reporting and Learning System - the old central
  system for reporting - their reports are still available and
  useful
  . NRLS has been replaced by LFPSE - Learn from Patient Safety
  Events
  . MHRA central alerting system - produces the current NEW alerts
• Older NPSA alerts and NRLS reports are still used and of benefit

REPORTING INSULIN ERRORS

. NRLS - National Reporting and Learning System - the old central system
for reporting - their reports are still available and useful
. NRLS has been replaced by LFPSE - Learn from Patient Safety Events
. Central database for recording and analysis of patient safety events
that occur in healthcare.
●
This then results in alerts being produced ie NatPSA (National Patient
safety alerts)

WHY INSULIN IS A HIGH-RISK DRUG

• Definition of High-Risk Drugs:
  Medications that have a higher potential for causing significant harm
  if used incorrectly.
• Why Insulin?
  ○
  Narrow therapeutic index.
  ○
  Risk of hypo- and hyperglycemia due to dosing errors.
  Between August 2003 and August 2009 the NPSA received 3,881 wrong dose incidents
  involving insulin.1
  ○
  Complex regimens requiring accurate patient understanding and clinical
  expertise.
• Examples of Errors:
  ○
  Wrong insulin type (e.g., rapid-acting instead of long-acting) .
  ○
  Incorrect dose or timing.
  ○
  Omitted doses in hospitalized patients.
  References: NPSA Rapid Response Report NPSA/2010/RRR013, June 2010
  1.

INSULIN TERMS AND TYPES

Insulin Terminology

Basal insulin
A long-acting insulin that's injected once or twice a day to provide a steady
stream of insulin. It helps process blood sugar when you're not eating.
Bolus/Prandial insulin
A short-acting insulin that's injected before meals and sometimes snacks to
provide an extra burst of insulin to process new sugar. The dose of bolus insulin
matches the amount of carbohydrates you eat.
Insulin pump
An insulin pump is a small electronic device that releases the regular insulin your
body needs through the day and night - so you don't need to do insulin injections.

Insulin Types and Characteristics

Basal
Prandial
Rapid acting
o Aspart (Novorapid®)
o Lispro (Humalog®)
o Glulisine (Apidra®)
Given shortly before or with food.
Analogue
Onset
60 min
Onset
10-20 min **
Peak
No peak
Peak
1-3 hours
Duration
18-24 hours*
Duration
3-5 hours
Ultra-rapid acting
o Degludec (Tresiba®)
o Aspart (Fiasp®)
Given shortly before or with food.
** Ultra-rapid acting insulins have an onset of 5-15 minutes.
Onset
90 min
Onset
30 min
Onset
30 min
Peak
2-3 hours
Duration
18 hours
Mixed short/intermediate
o Humulin M3®
Given 30 minutes before food.
"M3" indicates that 30% is short acting insulin.
Short acting
o Soluble insulin (Actrapid®, Humulin S®)
Given 30 minutes before food.
Mixed
Mixed rapid/intermediate
o NovoMix 30®, Humalog Mix 25®, Humalog Mix 50®
Given shortly before or with food.
The number in the brand name refers to the percentage of
the rapid-acting component.
Onset
10-20 min
Peak
1-3 hours
Duration
18 hours
Ultra-long acting
o Glargine U300 (Toujeo®)
* Ultra-long acting insulins have a duration of 36-42 hours.
Peak
4-12 hours
Peak
2-3 hours
Duration 7-8 hours
Human
Duration
18 hours
Intermediate acting
o Isophane/NPH (Insulatard®, Humulin |®)
Long acting
o Detemir (Levemir®)
o Glargine U100 (Lantus®, Abasaglar®, Semglee®)
@2020 Philip Newland-Jones and Nabil Boulos. All rights reserved. Pharmacy Management of Long Term Medical Conditions. Pharmaceutical Press. [March 2021]

NORMAL INSULIN SECRETION PATTERN

Main meals
800
Insulin secretion (pmol/min)
700
600
500
400
300
200
100
0600
1000
1400 1800 2200
0200 0600
Clock time (h)
O'Meara et al Am J Med 1990
89:11S-16S