Safer administration of insulin dr Helen Akester

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  • Dr Helen Akester

  • Masham/Kirkby Malzeard Surgery

  • 10th February 2011

NPSA (National Patient Safety Alert) issued in June 2010

  • WHY?

  • In UK 4-5% population have diabetes,

  • 20-30% are treated with insulin

  • Insulin identified one of top 10 high risk medications worldwide

  • Errors are very common-First national audit >14,000 diabetic pts in England and Wales showed prescribing errors in 19.5% cases


  • U.S study-up to 33% of medication errors related to Insulin. Errors twice as likely to cause harm as errors for other prescribed drugs.

  • Insulin has narrow therapeutic range, requiring precise dosage adjustments with careful administration and monitoring. NPSA report shows that 62%insulin errors were around administration with prescribing the most common factor. 15,227 incidents inc 6 deaths relating to Insulin in E and W between 2003 and 2009. Many incidents unreported.


  • Over 20 different types of insulin in use in various strengths and forms.

  • Range of devices for delivery inc. insulin syringes ( from vials), insulin pens

  • (prefilled/reusable) and insulin pumps.


  • Refresh your knowledge and understanding of insulin

  • Outline differences in administering insulin

  • Develop further understanding of range of available insulins and injection devices

  • Review common side effects of insulin and how to effectively treat them


  • Available as treatment since the 1920s

  • Most is genetically engineered (recombinant human insulins) to be more like the insulin the body makes

  • Different insulin treatments available that have been genetically modified to have different absorption profiles-known as insulin analogues ( see MIMS)


  • The right insulin

  • The right dose

  • The right time

  • The right way

The Right Insulin

  • All have a proprietary name eg Apidra, which must be stated when prescribing

  • All have an approved name eg Insulin glulisine

  • Can be easy to muddle eg Humalog,

  • Humalog 25 and Humalog 50

4 main insulin categories

  • Over 20 different types of insulin, classified according to their effect and action on the body:

  • Rapid Acting

  • Short Acting

  • Intermediate Acting

  • Long Acting


  • Works very quickly, <5-15mins

  • Take just before eating

  • Peaks between 30-90 mins

  • Duration 3-5 hours

  • Less likely to lead to hypoglycaemia than some other types of insulin


  • Works <30-60mins after injection

  • Peaks at 2-3 hours

  • Duration 5-8 hours

  • Short lifespan, injected several times daily


  • Longer lifespan, slower to work!

  • Starts <2-4 hours

  • Peaks 10-14 hours

  • Remains working 16 hours


  • Starts < 6 hours

  • Continuous level of activity for up to 36 hours

  • (sheet-fill in gaps)

  • Choosing type of insulin depends on clinical need, personal choice and ability to self manage their insulin regime

Insulin Regime

  • O.D regime-T2DM in combination with oral agents

  • B.D regime-consisting of soluble, or soluble plus isophane or fixed formulations of a mixture of back ground insulin plus fast acting

  • eg Novomix 30, Humulin M

  • Multiple injections-several times daily (4-5), mimic normal physiological profile. Inc. a SA or RA with meals and intermediate acting (basal) OD

  • IV insulin-variable rate insulin infusion-hospital admission not eating/drinking- insulin half- life of 3-5mins


  • Prescribed with IV glucose

  • 24hrs expiry date from when prepared

  • Giving set-low absorption tubing, may need to be primed

  • In T1DM discontinuation to coincide with commencement of usual regime and meal time

  • Cease 30 mins after Pts usual insulin commenced


  • Two strengths available:

  • U100-more frequently used

  • U500-eg Humulin R, unlicensed in UK

  • Soluble, 5x more concentrated than standard insulin, named pt basis by specialist, may be given by hospital pump


  • Ensure correct dose: inc. frequency of administration

  • Check C.Is inc. allergies

  • Check other medications inc. OTC eg Gliclazide

  • Check illness not exacerbated by insulin

  • Informed consent-ensure aware of proposed tx and effects, symptom relief, side-effects and mx, interactions with other meds inc. alcohol, need for monitoring, sick day rules, DVLA


  • Computer generated prescriptions are common-but if writing (hospital, home visits) use indelible ink

  • Do NOT abbreviate drug names: the word insulin should be used as well as brand name

  • Do NOT use decimal places

  • Clearly state drug dose,strength,route,frequency

  • Draw line through any amendments and initial change


  • Date prescription

  • Sign and write contact details

  • Write UNITS in full

  • Write form of delivery eg disposable pen/vial

  • Inc FULL name and address of patient

  • <12 years –inc Age or DOB


  • In UK most use 100units per ml (U100 Insulin)

  • A tiny drop can cause hypoglycaemia

  • Dose is crucial-different people have different needs

  • e.g children, underwt, overwt, ill

  • 5u can make one person unconcious and have no difference on another

  • Pts using SA insulin can adjust own dose to suit diet, exercise and their blood glucose


  • Common errors:

  • Pen upside down eg 12 units instead of 21

  • 10 x overdose due to use of abbreviation eg ‘U’ instead of ‘UNITS’ eg 6U can be mistaken for 60 units

  • Using ‘I.U’ as abbreviation for international units eg 6 iu can mistaken for 61 units

  • Prescribing/administration wrong type of insulin due to incomplete name eg Humulin ?I or S


  • Selecting wrong vial or cartridge

  • Using syringe not designated for insulin use NB Very concentrated so always use insulin syringe 100 units in 1ml ( or pen/pump)

  • Usually insulin injected S.C with short needle eg 5mm. Given I.M it works very quickly and can cause hypoglycaemia.

  • IV insulin always used diluted eg 50 units actrapid in 50ml 0.9% sodium chloride


  • U100 syringe can hold 1ml/ 100 units insulin

  • Other types-0.5ml 50 units

  • 0.3ml 30 units

  • 0.3ml syringe has half unit doses marked on if only small dose required

  • 0.5ml syringe has single unit doses marked


  • No need to insert cartridges

  • Packs of 5-pt should be advised to order at end of 3rd pen

  • Disposable needles-variety lengths-most common 5mm,6mm,8mm

  • Use new needle for each injection

  • Discard used needle in sharps container (safety clip device)


  • Miniature pumping device worn outside body

  • Connected to catheter located under the abdominal skin

  • Programmed to deliver insulin according to pt’s daily regime

  • Delivers steady small doses of insulin, Pt gives themselves bolus for meals/snacks

  • If disconnected-s/c insulin or variable rate infusion according to Pts finger prick blood glucose


  • Demands-dexterity, concentration, good vision, steady hand

  • Inject at 90o angle

  • Count to 10

  • Withdraw needle


  • Unopened vials/pens/cartridges-store in fridge

  • Check not vulnerable to freezing as will deactivate insulin

  • Check individual products packages for length of time can be used safely after opening e.g 4-6/52

  • Once open store at room temperature. Cold injection painful and absorption profile different

  • Store cartridges in their original box as small and be easily muddled

  • Do not leave exposed to direct sunlight

  • Never store pen with insulin pen needle intact


  • Self Mx /Empower Pt!

  • Unable to use pen/syringe involve health professional or carer

  • Pt safety: Obtain written consent

  • Educate to ensure right insulin, right dose, right time, right way

  • Correct procedure to reduce infection

  • Correct storage of insulin

  • Ensure f/u

  • Raise awareness of risks of preloading insulin-DOH/MHRA advise against predrawing insulin. If staff are asked to premix insulin the employing trust takes responsibility as this practice is not recommended


  • Most common side effect of insulin

  • Most feared by those receiving insulin

  • ‘undersweet blood’: low levels of glucose in the blood

  • Those with D.M on insulin a glucose <4mmol/l indicates hypoglycaemia

  • Occurs when pharmacologically raised insulin levels are not responsive to falling

  • insulin requirements

  • Body usually has good neuroendocrine defence system


  • 2 separate effects:

  • ADRENERGIC-results in counter regulatory process, adrenaline/ glucagon act to release glucose from liver, ‘fight and flight’ symptoms

  • NEUROGLYCOPEANIC-brain has high energy requirements, relies almost entirely on glucose for fuel, cerebral function measurably impaired when glucose <3.5mmol/l-irrational behaviour/aggression/drowsiness/seizures and eventually coma


  • MILD

  • Hunger, shakiness,nervousness,sweating,dizzy, light headed,sleepy,confused,

  • difficulty speaking,anxiety

  • Confirm BM reading

  • Able to swallow?

  • 200ml non diet fizzy drink e.g coke, 200ml fruit juice, 120ml lucozade,6 dextrose tablets or 3-4 teasp sugar


  • Moderate:

  • Conscious, confused or semi-conscious but able to swallow

  • Tx

  • Glucogel- 2 ampoules inserted into oral cavity-does not actually need to be swallowed


  • Severe:

  • Unconscious, absent gag reflex

  • Tx: Give glucagon I.M, I.V 10-20% dextrose

  • Once alert rpt as for mild hypoglycaemia tx

  • Then once blood glucose risen give L/A carbohydrate eg cereal/bics


  • Too much insulin/ too many tablets

  • Unplanned/ strenuous activity

  • Not enough food esp. carbohydrates e.g fasting/unwell

  • Too much alcohol e.g limit to small amt-and always eat with it

  • Delayed/missed meal

  • Drug interaction


  • Known as ‘fatty lumps’

  • Can be large and unsightly

  • Rarely troublesome, but tend to persist

  • Must vary site of injection from day to day

  • If insulin repeatedly injected into a fatty lump rate of absorption delayed



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