Our colleagues at NHSI (national patient safety team) recently reviewed understanding of blood glucose analysers following a trigger incident reported to the NRLS and have asked us to share their feedback with all NAMDET members;
Following an incident reported to the NRLS where the display terms on a blood glucose analyser were not understood and acted upon, we shared a questionnaire with users from different care settings in order to learn more. Although there was assurance that users who completed the questionnaire understood what the terms HI and LO mean on a blood glucose analyser, we wanted to share this issue with you for awareness. Please be mindful that some users who may not perform blood glucose monitoring frequently or who may have missed user training may be confused by such terms and therefore fail to act on them. We are confident that this is not a general concern but suggest that you may wish to review user awareness in your organisation, both with colleagues and patients who self-monitor, as an additional guarantee of good practice and understanding in this procedure.
Please pass this important information onto your medical device training colleagues and share at local and regional levels.