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Insulin errors and who gets insulin.

H

helli

Well-Known Member
Relationship to Diabetes
Type 1
I recently read
the National Diabetes Audit reported in 2017 that insulin error occurred in 40% of people with type 1 diabetes and 37% in those with type 2 diabetes.
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and wondered, what is an insulin error?

My initial thought was wrongly calculated bolus dose resulting in a hypo or hyper. However, on the (maybe flawed) assumption that most people with type 2 taking insulin will be taking a mixed insulin, they will not be calculating the dose so it is probably something else that results in an error.

Interestingly, the article also said
Insulin prescribing in the UK has tripled in the past decade, in particular due to an increase in use among those living with type 2 diabetes, now the largest group of insulin users.
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I don't know why but I was surprised by these statistics.
 
Inka said:
I assumed that would be for people in hospital @helli There was a lot about it a few years ago - how many errors they’d made with insulin, some dreadful errors.
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That seems to be the case. https://pharmaceutical-journal.com/...mprove-the-safety-of-inpatients-with-diabetes says
Insulin errors are commonly reported and are frequently associated with significant patient harm[1–3]. Results from the latest National Diabetes Inpatient Audit, published in November 2020, show that two-fifths of people taking insulin experienced one or more insulin error during a stay in hospital — an unacceptably high figure that has not significantly reduced since 2017[4,5].​
 
At the end of the day, we all make mistakes with our insulin from time to time and some of us consider ourselves to be the experts in our own diabetes management because we live with it every day, so it really doesn't surprise me that a large number of errors occur in hospital settings where most nurses haven't got any real understanding of insulin usage or how incredibly individual diabetes can be, plus being in hospital usually means you are ill or injured in some way which changes insulin needs from the norm and makes it more complicated and unpredictable.
 
Doesn't surprise me in the slightest that errors in doses occur in hospital. 99.9% of those doing 'Obs' get 'a drop of blood' right out of the middle of the finger pad, and then hold your finger in a vice like grip to convey it to the strip!
 
rebrascora said:
At the end of the day, we all make mistakes with our insulin from time to time and some of us consider ourselves to be the experts in our own diabetes management because we live with it every day, so it really doesn't surprise me that a large number of errors occur in hospital settings where most nurses haven't got any real understanding of insulin usage or how incredibly individual diabetes can be, plus being in hospital usually means you are ill or injured in some way which changes insulin needs from the norm and makes it more complicated and unpredictable.
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I sort of agree Barbara.

But the business of a Dispensing Nurse, coming round the Ward with personalised meds in accordance with the instructions from a Dr, who also has too little understanding of the individuality of the process, is a recipe for problems. Thus mistakes. Then there is the question of bolus timings; and the reality that hospital food is all too often inappropriate for carb counting or estimating.

I'm not sure how this can be resolved - providing appropriate care with safe practices. But I've experienced this personally and errors in hospital settings is, in my opinion, unforgivable and must be faced up to and resolved.
 
The last time I was in hospital about five years ago was for an ear infection leading to an operation. I insisted that I would use my own insulin while there. They were very reluctant but I insisted, finally having to see a Doctor to explain. I didn’t have CGM then and they did the finger prick tests. Again reluctantly and only because I pressed them. They wouldn’t let me use my own kit, and even stood over me while giving myself injections, bringing my insulin from the locked away medicine test. Finally they couldn’t provide me with the carb values of the food. My family brought in supplies …


Nick
 
rebrascora said:
At the end of the day, we all make mistakes with our insulin from time to time and some of us consider ourselves to be the experts in our own diabetes management because we live with it every day, so it really doesn't surprise me that a large number of errors occur in hospital settings where most nurses haven't got any real understanding of insulin usage or how incredibly individual diabetes can be, plus being in hospital usually means you are ill or injured in some way which changes insulin needs from the norm and makes it more complicated and unpredictable.
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There should be more education for sure, but some of the errors are awful, including completely unnecessary death. Wrong insulin, not understanding units, misreading or ‘correcting’ doses. When people go into hospital it’s perfectly reasonable to expect to be prescribed the correct drug and given the correct dose. It’s also perfectly reasonable to expect to be given your life-preserving medication when you’re unable to do it yourself. The rate of DKA for hospital patients on insulin is higher than you’d think, in the one place you’d think you’d be adequately cared for.
 
A few years ago I was in hospital. After the operation I was put into an induced coma. Then I had a few days in ICU followed by a few days when I could not sit up. During that time my blood sugar was all over the place - usually too low. I was noted as diabetic and so I "obviously" needed insulin even though I was unable to take any solid food. They could not get the dose right. It was only when I was able to sit up and take my metformin tablets that my blood sugar settled down. "They" would not listen when I said insulin was not right for me. After that first time in hospital I have been prepared up front. A couple of days off metformin and no insulin was fine.
 
Thankfully, when I have been in hospital, 8 have been "trusted" with my own insulin. I guess it would be difficult for them to take my pump away from me when it is attached.
The anaesthetist has been happy for my pump to manage during surgery. In the most recent operations, they have used my phone to monitor my CGM. So, thankfully, my local hospital understands enough about diabetes to leave it up to me. At least the orthopaedic department does.
Being unable to manage it myself is one of my biggest fears.
 
When I was 8 I had some kind of norovirus which sent me into DKA but with blood sugar in normal range. I was on a sliding scale IV and was scarily hypo within a few hours. I can barely remember it but I was so frightened and hallucinating. I tore the IV from my arm and got told off by the nurse before she tested my levels (finger-prick). Then it was "oh" and rushed to get glucose.
My mum was incredibly angry.
 
Bruce Stephens said:
That seems to be the case. https://pharmaceutical-journal.com/...mprove-the-safety-of-inpatients-with-diabetes says
Insulin errors are commonly reported and are frequently associated with significant patient harm[1–3]. Results from the latest National Diabetes Inpatient Audit, published in November 2020, show that two-fifths of people taking insulin experienced one or more insulin error during a stay in hospital — an unacceptably high figure that has not significantly reduced since 2017[4,5].​
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And we are constantly told from a young age to trust the experts, the professionals. As if they could know more about us than ourselves.
 
helli said:
Seems ironic to read how many people have their insulin taken from them when they are in hospital and have to rely on the nurses.
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Yes it just goes to show how difficult the diabetes management we do day-in day-out really is. I’d imagine it may also include missed or delayed doses where food is brought to someone, but no one gives the dose (or it’s given late)?

The larger number of T2s taking insulin than T1s has been the case for some time I think. The relatively small proportion of T1s in the population of PWD means that only a fairly small proportion of T2s have to need insulin before they outnumber the entire T1 population!
 
My mum was in hospital a few years ago with a broken hip. The night before the operation to fix it, the doctor refused to allow her to take any Levemir at all. She tried to explain multiple times that her blood sugars would be through the roof without it and she should at least take some, but nobody listened… then they were all really surprised when her blood sugars were in the 30s the next morning and they had to hastily put her on an insulin drip! Another time she was in one of the hospitals near us with pneumonia. The staff there were a bit nicer and after a day or so did let her do her own injections. They insisted on writing everything down though; mum was complaining to me that she kept waking up low in the morning so I suggested reducing her basal by a unit, which she did and woke up with a perfect 6 the next morning. Nurse was not very happy that she had changed the dose though (by one whole unit!), although softened when she heard the explanation. How these people think my mum has managed her injections on her own for the last 57 years, I have no idea…
 
And then there’s the time my daughter had her appendix out, aged 7, a year or so after she’d been diagnosed with diabetes. They put her on a sliding scale, the nurses had instructions that if blood sugar went above 14 they should increase the rate to x and if it went below about 7 they should decrease the flow to y. Well all night they had to come in and change it back and forth every couple of hours, which immediately says to me that the machine should have been set somewhere in between the two rates. The nurses aren’t allowed to deviate from the instructions they’ve been given though, and of course there was no doctor available to change them in the middle of the night. I get that they have to be very careful to try to avoid mistakes, some of the nurses looked quite scared to be adjusting such a dangerous medication though, and it did amuse me - can you imagine, if every time my daughter wanted to eat something, we had to have 3 people checking whether she’d done the carb count correctly?!
I was quite relieved when we were allowed to put daughter back on her own pump and I could take control again (which caused much interest among the nurses who all wanted to come and watch the cannula insertion!). Hospitals do usually have rules about dangerous medications being locked away so that they can’t fall into the wrong hands, they can’t do that when it’s attached to you though!
Diabetes is definitely a specialist subject and general ward staff seem to have very little knowledge of it. And of course they can’t know everything. They should know when to take advice though, and understand that people who have long-term medical conditions are probably quite used to how to deal with it themselves!
 
Though part of the problem may be that ward staff just aren’t used to people wanting to deal with it themselves. When I broke my hip last year, I had 4 weeks of rehab in a community hospital where I was told that “they’d never come across anyone like me before” - most insulin users, whether T1 or T2 (I’m pretty sure it would be mainly T2) were apparently only too happy to leave it all to the nurses.

Once- or twice-daily fixed doses are simple enough to cope with; introduce carb counting, bolus ratios, corrections and basal adjustments into the mix and they just don’t have the time, never mind the expertise.

But the risk in leaving it to the patient could be equally great. As one doctor explained to me “we don’t want your family suing us because while you were under our care you were confused and injected twice leading to a hypo you didn’t recover from”. I did suggest that risk was present wherever I was, but of course when I’m in hospital I’m their responsibility. Hence every bolus had to be recorded, note taken of BG before each meal and last thing at night, and proposed amendments to basal approved by a doctor.

I really do think hospitals are between a rock and a hard place on this one. Giving ward staff more autonomy while remaining risk averse is a difficult balance. Ultimately, which costs most - more, and better trained, HCPs, or compensation payments?
 
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You make a very good point @JJay. I have read a few posts in this thread and wondered whether the poster would have the same viewpoint if they were a "professional".
 
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