Award-winning tool emphasises ‘hospital insulin safety starts in the community’

A new resource raising awareness of insulin errors and their impact on people living with diabetes has been published.

Entitled, ‘Hospital insulin safety starts in the community’, the tool explains how healthcare professionals can help prevent insulin errors before people with diabetes reach the hospital.

Developed by the SHINE (Safe-Hospital-Insulin-Use) Study team at King’s College London in partnership with Wye Valley NHS Trust, it highlights system factors that contribute to errors and offers guidance on simple actions clinicians can take to increase safety.

Key strategies include improving information access during transitions of care and empowering people to manage their diabetes safely.

Christina Lange Ferreira, Doctoral Fellow in Diabetes at King’s College London, said: “We reflected that hospital insulin safety starts in the community.

“As a system, we need to better promote conversations about preparing for hospital admission – through annual reviews and structured education – and provide key safety-netting advice both actively and passively, especially for those at higher risk of hospitalisation.”

She added: “Community staff may not routinely consider hospital insulin errors, and the scale of the problem is not always on their radar.”

To reduce the risk of insulin errors in hospital, a second guide with key safety netting advice has been developed for people with diabetes to help them prepare for admission and is available as an infographic or a short animation.

Key recommendations include:

·       Notify hospital staff that you have diabetes

·       Keep an up-to-date list of your medications easily accessible

·       Bring your usual medications and diabetes management kit with you whenever possible

·       Self-manage your insulin in hospital if it is safe and you feel able

·       Use tools like ‘My Perioperative Diabetes Passport’ to plan care ahead of surgical procedures.

Christina noted: “Better preparedness, empowerment and sharing of key information can help mitigate some of the factors that lead to errors at the front door of hospitals.”

The two resources were jointly recognised with the Rowan Hillson Award 2025 from the Association of British Clinical Diabetologists, which celebrates excellence and innovation in improving insulin safety and diabetes care across the UK.

“Receiving this award is a real honour and reflects the importance of this work in improving insulin safety, as well as the value of collaboration between people living with diabetes and healthcare professionals in developing practical, impactful solutions,” said Christina.

These resources build on the SHINE Study, a co-design project involving older adults with diabetes and multiprofessional perioperative staff.

SHINE sought to develop an intervention to improve hospital insulin safety by mapping the interacting factors that contribute to errors.

Through an iterative co-design process, the researchers, staff and people with diabetes created the SHINE Wheel – a logic model focusing on two priority areas: transitions of care and right insulin, time and way.

The model identifies eight key actions and 12 outputs, centred around solution themes such as:

·       It is all connected

·       Right insulin, right time, right way

·       Safer transitions of care

·       Patient empowerment

·       Organising and providing care effectively

·       Developing and supporting the workforce.

To access the two new resources, click here. The findings of the SHINE Study can be found here.

The animation, ‘Empowering people with diabetes to prepare for a safer hospital stay | 2 min guide | SHINE Study’, is also available to watch on YouTube here