National Patient Safety Alert
Published: 8 December 2023
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.