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Originator: National Patient Safety Alert - DHSC

Issue date: 08-Dec-2023 09:49:33

This alert has been issued to:
  • Care Trusts
  • Mental Health Trusts
  • Specialists Trusts
  • Learning Disabilities Trusts
  • Mental Health & Social Care Trusts
  • Ambulance Trusts
  • Mental Health & Learning Disabilities Trusts
  • Acute Trusts
  • Community Trusts

  • Other contacts
  • Independent Healthcare Providers (registered with CAS)
  • Clinical Commissioning Groups
  • NHS Regional Offices
  • Social Care Providers (registered with CAS)
  • Special Health Authorities
  • Territorial CMOs in Northern Ireland, Scotland & Wales
  • GP - Locum
  • NHS 111 and Out of hours providers
  • GP Practices
  • Integrated Care Boards
  • DHSC Supply Disruption - Medicines
  • Community Pharmacy
  • Primary Care Networks
  • GP Practices 1

Action category: Action

Title: Potential for inappropriate dosing of insulin when switching insulin degludec (Tresiba) products

Broadcast content:

A Medicine Supply Notification issued on 24 May 2023, detailed a shortage of Tresiba® (insulin degludec) FlexTouch® 100units/ml solution for injection 3ml pre-filled pens. Advice on how to manage this supply issue can be found on the Medicine Supply Tool

The Medication Safety Officer (MSO) network has highlighted that in response to this shortage, some patients may have been switched to Tresiba® (insulin degludec) FlexTouch® 200units/ml solution for injection 3ml pre-filled pens. Tresiba® FlexTouch® pen delivery devices dial up in unit increments rather than volume.

However, a small number of patients have been incorrectly advised to administer half the number of units.

MSOs have highlighted five reports of patients being incorrectly advised to reduce the number of units of insulin to be administered. These reports suggest that errors have occurred at the prescribing, dispensing and administration stages of the medicine journey. One case described a patient requiring treatment in hospital for diabetic ketoacidosis because of a reduced insulin dose.

This National Patient Safety Alert provides further background and clinical information and actions for providers.

Additional information: NHS England Regions: please cascade this alert to community pharmacy.

Alert reference: NatPSA/2023/016/DHSC

Action underway deadline: 11-Dec-2023

Action complete deadline: 22-Dec-2023


Contact our helpdesk

Email: safetyalerts@mhra.gov.uk

Medicines and Healthcare products Regulatory Agency