1. RISK Regional Insulin Safety and Knowledge Project A focused collaboration between the Foundation Trusts of the North East of England

2. Over 3 million people in the UK have diabetes The majority will use insulin during their lifetime Errors involving insulin are common Errors involving insulin are under-reported Errors involving insulin are avoidable Errors involving insulin cause harm Errors involving insulin can kill Diabetes affects 1 in 6 in-patients …. Background….

3. Stakeholder engagement Workstreams identified Project Manager appointed Workstream output agreed £ Implementation…

4. Six Sigma on Communication Insulin Prescription Chart Professional Education Package Insulin Passport and Booklet RISK

6. Forthright poster impact on wards

7. Insulin prescription chart One chart One prescription standard One prescription method Training for users Audit of use

8. 01/04/12 007 10 20 NE super hospital 654321 Dr Wonderful 123456 Mrs Noriski 1/1/11 The presentation Anywhere Dr Wonderful 654321 Dr Wonderful Fab farma 01/04/12

9. Useful Guidance on the front of the chart Insulin must be prescribed on the e-prescription or drug chart in addition to this insulin chart.

10. Discharge - a moment of risk Lispro (Humalog) 12 10 Glargine (Lantus) 24 X XX wonderful 654321 wonderfulNot Wonderful Fab pharma 2222

11. Insulin prescription chart progress One chart One prescription standard One prescription method Self administration Training for users Audit of use Eight FTs Six Sigma Standard dose Clear “permissions” Education package NDIA in place

12. Professional Education package Standardised for region Include available resources NHS Diabetes Suite of safety e-learning modules Insulin chart at core of training Six Sigma communication approach

13. Insulin Passport and Booklet NHS organisations should ensure by 31 August 2012: That adult patients on insulin therapy receive a patient information booklet and an Insulin Passport to help provide accurate identification of their current insulin products and provide essential information across healthcare sectors.

14. Insulin Passport & Booklet Passport supplies Agreed leaflet for region –Content –Logos –Printing Focus groups Acceptability Usefulness Informed roll out for deadline

15. RISK Final Board meeting and write up end April Recommendations to FTs and CCGs Implementation by August 2012 On-going review via Diabetes Network On-going audit within NDIA Legacy………

16. RISK Project Team NHS Diabetes Gillian Johnson Project Manager Jan Finn Workstream Leads Jean Macleod; North Tees, Raz Nayar; Sunderland, Nicky Leech; Newcastle, Sue Robson; NorthTyneside. Safer Care NE Emma Nunez Not forgetting…… All those in the workstreams and focus groups