Source · HSSIB Patient Safety Investigation
Insulin: supporting safe administration in inpatient settings
Published 26 March 2026
Published
Medication
Long-term conditions
Hospital care
This investigation examines risks to safety when patients who take insulin are admitted to acute hospitals. Insulin is a high risk medication and remains one of the most common causes of harm from medication errors in the NHS.
Summary
3 recommendations
2 observations
Safety Recommendations
R/2026/076
Department of Health and Social Care
HSSIB recommends that NHS England/Department of Health and Social Care sets out the expectations and responsibilities of NHS trusts, integrated care boards and NHS England for the oversight and assurance of inpatient diabetes care. This should support organisations to implement and act on improvements shared in national guidance, recommendations and audit data. It should also include how existing functions (Getting It Right First Time and the Diabetes Care Accreditation Programme), and those currently in development (new National Diabetes Audit for Inpatient Care) can be more closely aligned and utilised to help better understand and respond to challenges relating to the safety and quality of inpatient diabetes care.
No response published on HSSIB's website
R/2026/077
Royal College of Physicians
HSSIB recommends that the Royal College of Physicians reviews and acts on new data and outcomes of studies about adopting blood glucose into NEWS2 and shares any decisions it makes. This is to encourage understanding and support consideration of how blood glucose issues can be recognised early and escalated to mitigate harm.
No response published on HSSIB's website
R/2026/078
CQC
HSSIB recommends that the Care Quality Commission assesses how it can use data from the Diabetes Care Accreditation Programme and the new National Diabetes Audit for Inpatient Care as part of its regulatory activity. This is to ensure that known challenges in inpatient diabetes care, and knowledge of providers that do not report national diabetes audit data, are considered to provide intelligence in support of regulatory activity.
No response published on HSSIB's website
Safety Observations
Observation 1
Observation
Organisations and individuals involved in the provision of clinical undergraduate and pre-registration education, and trust preceptorship/ induction programmes, can improve patient safety by using the findings of this report to prioritise diabetes care and insulin management education and training as appropriate.
Observation 2
Observation
Professional regulators and royal colleges can improve patient safety by reviewing this report and disseminating appropriate communications to their registrants and members in relation to understanding their expectations in providing safe diabetes care.