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PSNet: Patient Safety Network
Journal Article

Improving the quality of insulin prescribing for people with diabetes being discharged from hospital

Bain A, Silcock J, Kavanagh S, et al. BMJ open quality. 2019;8:e000655.

Medication errors involving insulin are common, particularly in hospitals and at point-of-care transfers. Using a continuous improvement methodology, a multidisciplinary project team carried out three “plan-do-study-act" cycles to introduce locally tailored insulin discharge prescribing guidance. Adherence to the guidelines improved from an average of 50% to 99% after introduction of a poster and then checklist forms of the guidelines. This small, qualitative study in one hospital diabetes ward suggests that small iterative changes can improve insulin discharge prescription quality. A PSNet primer expands on the topic of medication reconciliation.