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Posted 27 Jan 2015 in Medication

It could be as simple as writing 4 instead of 4.0 so a patient isn’t given 10 times the units of insulin intended. Or maybe it’s knowing which insulins should be given before a meal and which after. The Health Quality & Safety Commission’s new series of ‘one steps’ is packed with ways to help reduce harm from high-risk medicines, the current focus of the Commission’s Open for better care national patient safety campaign.

Insulin is the subject of four of the ‘one steps’, which are modelled on a UK Patient Safety First campaign approach that provides actions frontline staff and managers can quickly get involved with, and supports and builds on improvement work already being done.

Each of the New Zealand ‘one steps’, available as downloadable PDFs from the Open website, sets out the background and risk of the medicine in question. The ‘one step’ then provides an activity to help clinicians evaluate the situation in their ward, unit, hospital or other facility, suggests what to consider when reviewing the results, and offers next steps that might be taken.

International evidence suggests insulin is frequently associated with adverse drug events, with errors identified at all stages of the medication management process: prescribing, administration, dispensing and monitoring.

While often the events may not cause serious harm, they can cause patients distress and confusion, impact on their confidence in managing their condition, and prolong their hospital stay.

Johana Marcroft, Lead Pharmacist Medication Safety at Auckland District Health Board, helped test the ‘one steps’ and says: ‘Insulin is a recognised high-risk medicine. It is commonly prescribed and there are a lot of errors with it. There is confusion over brands and preparations and the correct way to prescribe it. So it is a really good choice for a “one step”.’

She says the ‘one steps’ will be a valuable tool for identifying insulin issues. ‘Often you have a gut feeling something is not right but this is a really good way to pinpoint exactly where the problems are.

‘The ‘one steps’ have the potential to be very useful. I can see a role for them with all clinicians.’

A dispensing insulin in community pharmacies ‘one step' is already available, along with others on medicine management and prescribing in hospitals, with one on administration and monitoring in hospitals coming in February.

‘One steps’ on potassium chloride infusion and concentrated potassium ampoules are also already available.

To download, go to