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The inpatient diabetes team at University Hospital Southampton NHS Foundation Trust recently launched D1abasics, an initiative that aims to improve inpatient care for people with diabetes. In this blog, Diabetes Consultant Mayank Patel and Inpatient Diabetes Specialist Nurse Paula Johnston outline the approach and explain how it will equip staff across all specialties with the basic knowledge to care safely for people with diabetes in hospital. Nearly one in five inpatients in UK hospitals has diabetes.[1] Where we work at University Hospital Southampton, we have 1200 inpatient beds, meaning that over 200 of our patients have diabetes at any point in time. As the prevalence of diabetes increases across the population, that figure is expected to rise to one in three over the next few years. When people with diabetes are admitted to hospital, more often than not, it is for reasons other than diabetes—recent data suggests that at least 90% of patients are in hospital for reasons other than their diabetes.[2] Although not all forms of diabetes require complex additional intervention, diabetes management is often thrown out of sync by a hospital stay. For this reason, it’s vital that healthcare professionals in all specialties understand the basics of managing diabetes, including the differences between type 1, type 2 and other forms of diabetes. Worryingly, research shows us that this isn’t the case—the most recent Diabetes Getting It Right First Time (GIRFT) national report highlights nationwide failures in monitoring patients with diabetes, a high prevalence of insulin errors and a high rate of diabetic ketoacidosis in patients with type 1 diabetes.[2] The report indicates a widespread lack of knowledge across healthcare professionals about the fundamentals of caring for inpatients with diabetes. Our own experience as a diabetes inpatient team bears this out; we come across many doctors, nurses and other professionals who aren't aware of the most basic principles of diabetes management, or who lack confidence to apply their knowledge safely. A solution to help staff understand the basics of inpatient diabetes care As a team, we realised the situation was giving us an unsustainable workload and putting patients at risk. We often receive calls from junior doctors who are not familiar with the most basic principles of diabetes care, and from wards asking us to visit patients for simple blood sugar management decisions that could be taken by anyone with the right knowledge, often by using our existing app-based guidelines. These requests take our attention from those patients with diabetes with the highest level of need who require our specialist support. We needed to do something to make sure all inpatients with diabetes are cared for safely, whichever ward or specialty they end up in, so we came up with a plan. With project management support and funding from Diabetes UK, we developed the D1abasics campaign, which aims to make sure every person working in the hospital understands the basics of diabetes care. We have produced banners, lanyards and other resources to provide quick reference points for staff while they are providing care for a person with diabetes. D1abasics is an acronym that covers different aspects of care including identifying patients with diabetes, listening to their concerns and views, understanding the importance of blood glucose monitoring and timely insulin administration in patients with type 1, and recognising the impact of other medical conditions, medications and treatments on diabetes control. You can access these resources at the bottom of this page. We have also visited every ward in the hospital to talk about D1abasics and explain what we’re trying to achieve. It’s really important that new staff are on board from the beginning of their time at the hospital, so we’re embedding D1abasics training in the induction process—in July, we will be seeking to reach up to 500 new starters about the initiative, via a recorded ‘introduction to diabetes in hospital’ video, as part of their hospital induction. Diabetes has an image problem which results in a reluctance among some healthcare professionals to get involved in aspects of diabetes care, as it seems complex and unpredictable. One of the aims of D1abasics is to demystify diabetes and increase people’s confidence that they can provide safe care. Part of this is helping people understand when they can do it themselves, and when they need to ask for our help—there will of course be times when we need to offer specialist care to patients whose diabetes is not responding to standard interventions, or who have complex medical situations. Our hope is that D1abasics will free up our time to focus on those patients that really need our input. Engaging staff and patients in the process While we were developing D1abasics, we spoke to staff about what would most help them and tried to understand the elements of diabetes care that were causing patient safety issues. We also asked patients for feedback, which was really helpful as they helped us see areas where slightly changing the language would make our messages clearer. The patients we spoke to were very grateful for the initiative, as going into hospital can be worrying for people with diabetes. Measuring impact and rolling D1abasics out to other hospitals We’re very hopeful that D1abasics will make a tangible difference to the safety of people with diabetes staying in our hospital. Over the next few months, we’ll speak to ward managers and other staff to get their feedback on the difference the resources and training are making. We’ll also be keeping tabs on the quality of referrals we receive and the number and nature of incident reports involving patients with diabetes. The issues we have identified are not confined to Southampton, they are present in every hospital trust in the country. Since launching D1abasics, we’ve had a lot of interest from people working at other organisations, and we are keen that other hospitals use the resources. We left our hospital logo off our materials on purpose—we don’t ‘own’ the initiative and if it can be used and adapted to improve care and outcomes for people with diabetes, we’re all for it! Access D1abasics resources Related reading Top picks: 5 key resources about diabetes Improving safety for diabetic inpatients: 4 key steps (Partha Kar) “I felt lucky to get out alive”: why we must improve hospital safety for people with diabetes References 1 Dhatariya K, Mustafa O, Rayman G. Safe care for people with diabetes in hospital. Clin Med, 15 January 2020 2 Rayman G, Kar P. Diabetes: GIRFT Programme National Specialty Report. NHS, November 2020

In this blog, Jayne Flood, Falls Prevention Practitioner at East Kent Hospitals NHS Foundation Trust, describes how her team introduced ‘yellow kits’* to assist patients at high risk of falls in A&E, and evaluated their impact. *Developed in partnership with Medline Industries Ltd. In 2020-21, the number of people visiting the A&E department at the East Kent University Hospital Trust (EKHUFT), one of the largest trusts in the south east, increased by up to 25%. At that time, we noted a surge in cases of falls in A&E, particularly those resulting in severe harm. The risk factors were clear: A&E departments were busier than they had ever been The quality of health in patients seeking help at A&E was declining Those seeking help had longer-than-usual waiting times in A&E departments There was no clear way for staff to indicate which patients they had assessed as having a high risk of falling Falls with harm are not only devastating to patients and families, but they also have considerable financial implications for healthcare providers. For example, the estimated cost of a single fractured neck of femur (NoF) or hip is £26,000.[1] In 2020 alone, EKHUFT recorded five NoF cases in just one A&E department, representing a bill of £130,000, excluding possible litigation costs. Implementing Yellow Kits to prevent falls in A&E To try and tackle the increasing number of falls we were seeing, we decided to trial the use of yellow kits in A&E. These kits act as a visual cue for staff, helping them to quickly identify patients at risk of falling. Each yellow kit contains a small yellow fleece blanket and a pair of yellow double-tread falls prevention slipper socks. We used our FallStop four-step approach to introduce the yellow kits: Step 1: Ensure you have the support of everyone in the department and senior management It is very hard to identify effectively, at a glance, whether a patient is at risk of falling, and I am aware of how upsetting patient falls incidents can be for staff. Issues often arise at handover as it happens very quickly and information about patients most at risk of falling is often not passed on - until it’s too late. I knew A&E staff would welcome an intervention to help raise their awareness and keep them vigilant. We made sure we had the support of all A&E staff - senior management, healthcare workers, porters and housekeeping staff - which meant that as the results of the evaluation emerged, everyone involved could see the benefit and share in the success of the initiative. Step 2: Integrate visual cues into the care protocol to help staff manage patients at high risk of falling We chose blankets and socks for the yellow kits as they are items that stay with the patient throughout hospitalisation, regardless of location. They can also go home with the patient. The bright yellow colour reminds all staff that extra precautions need to be taken with particular patients, and that they should act decisively if they see these patients trying to move around unassisted or attempting to get off the trolley. The yellow kits also help ward staff during patient transfers, as each patient has already been identified as a falls risk, triggering a full fall risk assessment, in line with Trust guidelines. Step 3: Make the case for the financial impact of not taking action There is nothing more frustrating than knowing there is a simple solution that works, and being unable to implement it as others - whose support you need - just see additional costs. I needed to show the financial burden of ignoring the problem, or only addressing its symptoms, to hospital management. As mentioned, the total cost of care for a hip fracture is £26,000 and there have been five NoF fractures in our A&E during 2020. We needed to prove the effectiveness and value of visual cueing as an intervention, so we developed a single site evaluation of the intervention, with clear outcomes. The program started to develop its own momentum as we demonstrated that yellow kits could help us protect our patients and cut long-term costs at the same time. Step 4: Ensure education before, during and after the intervention To make the intervention effective, we spent time with staff in A&E, particularly in the early stages, to ensure they fully understood when to use the kits and what they mean. We ensured that all staff in the department knew which patients they should issue yellow kits to. We developed a clear protocol for issuing kits: Presenting due to a fall Acutely unwell (for example, respiratory compromised, diabetic ketoacidosis, heart problems) Patients with confusion due to dementia or delirium with any of the following features: agitation, wandering, inability to use the call bell reliably, challenging behaviour, reduced safety awareness and disorientation Likely to attempt to mobilise on their own and unsafe to do so Alcohol or drug misuse causing challenging behaviour We also ensured that staff from other departments working with A&E understood the need for extra vigilance around patients with yellow kits. Medline, the company that supplies the kits, provides educational materials such as posters for staff notice boards, storerooms and public spaces, which we used to promote the initiative. We also involved our communications team to help promote yellow kits through the staff newsletter and intranet, and even got our Chief Executive on board to promote the project through her podcast! The impact of yellow kits on falls in hospital So, did the yellow kits work? In short, 100% yes! The kits empowered A&E staff to think and work differently, and they were pleased to be part of this highly effective initiative. The trial ran for six weeks, and over this period, we lowered the number of falls by 50%. In fact, the only patients who fell were those who did not have a yellow kit. The story was the same for patients admitted to wards - not one fell in the first 24 hours, which is the period when most falls would usually happen on wards. Since the evaluation, we have continued using the kits in A&E and have also been given funding to use them in our Acute Medical Unit. I shared the results of the trial on Twitter and the yellow kits went global! There are now yellow kits being used in A&E departments up and down the UK and some trusts are trialling the scheme in their frailty units. There are also hospitals in Chile, Spain and Australia now using yellow kits. To find out more about yellow kits and the FallStop programme, follow Jayne on Twitter. Related reading East Kent Hospitals University NHS Foundation Trust's FallStop programme FallStop: Winner of the 'Professionalising patient safety' category 2019 National Audit of Inpatient Falls (NAIF) Annual report 2021 How do occupational therapists contribute to patient safety? Community thread: Red walking aids References 1 NHS Digital. October 2021

In this blog, Claire Cox, Patient Safety Learning’s Associate Director, talks about the opportunities to improve patient safety and the risks associated with the use of barcode technology in healthcare. As a nurse working in the NHS for over 25 years, I’ve seen first hand how technology has transformed patient care. One of the biggest changes in recent years has been the introduction of electronic scanning. We scan patient wristbands, which are printed with unique barcodes, for many reasons: Patient identification: ensuring that treatments, procedures and diagnostics (such as blood tests, X-rays and scans) are matched to the correct patient. Medication administration: ensuring the right patient receives the correct drug at the correct time. Theatre and surgery safety checks: confirming a patient’s identity before they undergo surgery, reducing the risk of wrong-site or wrong-patient procedures. Blood transfusion safety: ensuring the right blood type is matched to the correct patient to prevent transfusion errors. Specimen labelling: avoiding mix-ups in laboratory samples by linking them directly to the patients' records. Tracking patient movement: monitoring patient transfers between departments, which helps with bed management and continuity of care. In theory, it’s a fantastic safety net. However, in practice it’s not always that simple. If we take scanning for medication as an example, the idea behind barcode scanning is brilliant. We scan the patient’s wristband, scan the medication and the system cross-checks everything to flag up any prescription issues, the correct patient weight, allergies, previous doses, interactions with other medication and of course… the correct patient. It’s meant to reduce medication mistakes and improve efficiency. And when it works, it does just that. But ask any nurse on a busy ward and they’ll tell you about the times it doesn’t go so smoothly. This blog will uncover some of the ‘workarounds’ we are using to enable us to do our job when the ‘system’ lets us down. What are the challenges? Technical glitches and system downtime One of the most frustrating issues is when the scanner simply refuses to work. Maybe the barcode on the medication is damaged or the scanner won’t read the patient’s wristband. This means wasted time trying to troubleshoot or calling IT for support. If the entire system goes down (which happens more often than I’d like), we have to revert to manual documentation. This not only slows us down but also increases the risks of getting it wrong—the wrong patient, wrong drug, wrong time, wrong dose, exactly what the system was designed to prevent. With the increase of patients being placed in non-clinical areas and corridors (what NHS England describes as ‘temporary escalation spaces’), you find that internet access is not always readily available in these spaces and there is Wi-Fi dead spots. The wristbands and the blood labels are generated by us and then sent to mini printers that print and dispense wrist bands; we have hundreds within our trust. The printers often require software updates, usually at different times. As a nurse I don’t know how to update these printers—so they end up not working. The point of escalation in these instances would be to call the IT team. However, the last time I did this I was in a queue for over 30 minutes. I haven’t the time for that, neither has our ward clerk. So, in the meantime the printer remains unusable and we revert to workaround measures. Issue Workaround Risk Wi-Fi dead spot. Override option on scanner. Able to give incorrect drug to incorrect patient—no alerts will be visible Printer not working—due an update. Print out at a different printer. Risk of picking up a different blood label, wrist band—as this may be the only printer working on the ward. Patients may get mixed up, given the wrong drug, wrong blood in tube, etc. Whole system down. Revert to written wrist bands and blood labels. Transcription issues. Workflow disruptions and delays With so many competing priorities, it’s a race to get everything done when you are working on a busy ward. Scanning every medication and waiting for the system to verify it can slow us down significantly, especially when caring for multiple patients. The process may be safer in theory but, when you’re juggling urgent patient needs, these extra steps can feel like a hurdle rather than a help. We should be scanning each patient individually, then going to the electronic drug cupboard to collect the medication. However, when every nurse on the ward is doing the same thing, a queue forms. You could be in that queue for 30 minutes or more. Once you have waited your turn—you scan the patient again, administer the medication, then start again for the next patient. We can be caring for up to eight patients at a time—all with multiple medications. We haven’t the time to wait in the queue—our morning drug round may start at 8 am and if we scanned as policy states, our drug round will not be over until lunch time and then it starts again! Time critical medication such as Parkinson’s and epilepsy drugs are often delayed because of this. Issue Workaround Risk Caring for many—unable to queue due to time. Scan one wrist band to get the drug cupboard open. Take ALL medications for ALL patient in numbered pots; e.g. bed number 1= pot labelled 1. Wrong patient, wrong drug, wrong dose. Drug cabinet far from ward area. Print multiple wrist bands and have them in your pocket. Wrong patient, wrong drug, wrong dose. Overreliance on technology While barcode scanning is designed to catch problems before they happen—for example, providing the medication to the wrong patient—it can also create a false sense of security. Some staff trust the system so much that they ‘forget’ to double-check what they’re administering. I’ve seen cases where the scanner didn’t flag an issue, but a second manual check revealed a potential mistake. No system is fool proof and human judgment is still essential. Issue Workaround Risk Blood administration—alert and checklist fatigue, over reliance on computer system information. No second checking. Wrong patient, wrong blood, wrong drug. Alert fatigue and workarounds Another challenge is the constant alerts. The system is designed to notify us about potential drug interactions, duplicate doses or allergies, but sometimes it feels like we’re bombarded with warnings. Often these warning are because of a previous incident and the pop-up is seen as the solution. When you’re dealing with dozens of pop-ups, it’s easy to develop ‘alert fatigue’ and start ignoring them, which is dangerous. Issue Workaround Risk Multiple alarms flagging and ‘hard stops’. Alerts overridden, checks on the scanner blindly ticked off the checklist. Wrong patient, wrong blood, wrong drug. Training and adoption challenges Not all staff are equally comfortable with technology and training can be inconsistent. New nurses, agency staff and those who aren’t used to the system may struggle, leading to mistakes or delays. And when changes are made to the system, not everyone gets the same level of training, leaving gaps in understanding. Training is often seen as the solution to this problem; it in in some cases, but there is far more to it than training. Integration issues Ideally, the scanning system should integrate seamlessly with electronic health records (EHRs) and pharmacy databases. Unfortunately, that’s not always the case. Sometimes, medications don’t appear in the system properly or there’s a delay in updates. This creates confusion and extra work as we double-check records manually. Patient-specific challenges We also face issues with patient wristbands. If a wristband is missing, damaged or poorly placed, scanning can be a nightmare. In critical situations—like when a patient is unconscious or in distress—trying to scan their wristband adds another layer of complexity we don’t always have time for. In healthcare, ensuring patient safety requires a deep understanding of how work is actually performed, known as 'work as done', rather than how it is ideally designed or imagined ('work as imagined'). The gap between these two perspectives can have serious consequences, making it essential for healthcare leaders to recognise real-world challenges and build systems that support safe and effective care. Issue Workaround Risk Administering a sedative for a combative patient. No scanning—override device. Wrong patient, wrong blood, wrong drug. What are the potential solutions? Understand the work system Healthcare is a complex, adaptive system where variability is inevitable. Policies, procedures and best practices often represent 'work as imagined', providing a framework for care delivery. However, frontline clinicians operate in dynamic environments where unexpected challenges arise. By studying 'work as done', organisations can identify discrepancies, improve workflows and implement practical solutions that enhance patient safety. Balancing accountability Achieving patient safety requires a careful balance between accountability and learning. A just culture differentiates between ‘human error’, at-risk behaviour and reckless actions. Instead of blaming individuals for system failures, organisations should focus on systemic improvements while holding individuals accountable for making safe choices. This approach promotes trust, engagement and continuous improvement. By involving frontline staff in the design, testing and implementation phases of introducing a new electronic system—or any new procedure, policy or tool—you may uncover these workarounds much sooner and be able to design them out. Addressing technological gaps When looking into new technologies to support healthcare, patient safety needs to be considered in the designed, development and implementation of new software and products. This means looking at how they are used in practice. It is not simply enough to put these in place, there also needs to be the infrastructure in place to support their operation. On some of the issues flagged earlier in this blog, improvements such as eliminating internet dead spots and having printers which manage their own updates would be small changes that could have a significant impact on how barcode scanning is used in hospitals. Concluding thoughts To bridge the gap between imagined and actual work, healthcare teams need psychological safety—the confidence to speak up about risks, inefficiencies and errors without fear of punishment. When staff feel safe to share their insights and concerns, organisations gain valuable real-world feedback, leading to proactive improvements. A culture of openness encourages learning from near misses and fosters a collaborative approach to safety. I had some reluctance to share this blog, particularly when working at the organisation where I encountered these issues. However, these workarounds and issues are not just within my practice, this is happening across the country in some shape or form. You just need to be inquisitive and look without judgement. Share your experiences What are your experiences of barcode scanning? What are the challenges you face? What workarounds do you have to use to do your job? Please comment below—you’ll need to be a hub member and signed in (sign up here). You can also email us at: [email protected]. Further reading on the hub Putting the writing on the wall: Explaining work as imagined vs work as done (by Claire Cox) Work as is done, work as imagined Electronic observations – how safe is it?