Creating sustained and positive changes to patient safety: reducing insulin administration errors in a district nursing service.

Administering insulin in a patient's own home is perceived as a simple nursing intervention, and one that is regularly delegated to newly qualified staff, agency and bank staff. However, without robust processes and clear, easy-to-follow nursing documentation in place, a simple nursing intervention can easily lead to an avoidable medication error and patient safety incident. This article describes the steps one trust has taken to combat insulin administration incidents. The article describes the use of a Plan, Do, Study, Act (PDSA) cycle to help test changes and roll out sustainable transformation. It describes some of the challenges faced, alongside the solutions tested and embedded into practice.