Case study: ePrescribing systems and insulin combinations

The National Patient Safety Team were contacted regarding an incident where a patient had been prescribed two similar types of insulin, with no clinical rationale, resulting in the patient suffering a drop in blood glucose level.  The enquirer believed that the electronic prescribing systems should have alerted the prescriber to this combination. 

Working with colleagues in NHS Digital (now part of NHS England), we were aware that staff can often experience alert fatigue caused by too many low-severity alerts.  Insulin is often designated a ‘high risk’ medicine however, so highlighting this issue and supporting the introduction of an alert into ePrescribing systems was considered appropriate.

he issue was presented at an ePrescribing masterclass monthly webinar where NHS organisations share learning to support quality improvement in patient safety.
It was also shared with the ePrescribing Risk and Safety Evaluation (ePRaSE) team, who included an associated test script in relation to insulin combinations in the latest version of the NHS-funded simulation tool.  This enables organisations to assess the configuration of their ePrescribing system to reduce medication error risk.

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.

In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.