Standard Operating Procedure for implementing insulin passport/insulin safety card and the patient information booklet (NPSA/2011/PSA003)

Background to these tools/why do we need them:
Between November 2003 and November 2009, over 16,000 incidents involving insulin were reported to the National Patient Safety Agency (NPSA), resulting in several deaths and serious harm. An alert was issued in 2010 recommending all Healthcare Professionals (HCPs) involved in prescribing/dispensing or giving insulin should complete the NHS Diabetes e-learning package on Safe Use of Insulin. This can be accessed on:

Participants need to register first using their ESR number. GP practice staff and nursing homes can contact Gwen Oates at Virtual College to get their place of work registered by contacting:

In 2011, the NPSA published another alert, requiring that all adults aged 18 or over using insulin should be given a patient information booklet explaining that mistakes can be made in the prescribing, dispensing and giving of their insulin. Patients should check they are being given the correct insulin, especially as some insulins have similar names but very different action profiles. They should also carry an insulin passport with them at all times, to show HCPs which insulin and device they are using.
The NPSA has produced a patient information booklet and insulin passport. A shorter version of the booklet is available and can be printed from the NPSA and NHS Diabetes websites. Insulin safety cards are available for Eli Lilly, Novo Nordisk and Sanofi insulins, which have been agreed by the NPSA as suitable alternatives to the passport. However, organisations should record on their risk registers if these are being used instead of the NPSA tools.
It is the responsibility of the prescriber to give out the passport/insulin safety card and the patient information leaflet. This includes when initiating insulin and giving repeat prescriptions
The patient information booklet:
The NPSA booklet “Diabetes: insulin, use it safely” has 11 pages of writing and so the shorter version may be more suitable. This can be printed from the NHS Diabetes website:

Trust logos can be included by contacting June James on:

How to use the leaflet:
Give the leaflet to the patient and encourage them to read it. Explain that several insulins have similar names and this leaflet is highlighting this.
Record that the patient information leaflet has been given. If working in a GP practice, record the appropriate Read code in the patient’s notes:
Insulin alert patient information booklet given 8CE01
Professional judgement not to engage patient with insulin alert requirements 8IF..
Insulin alert patient information booklet information discussed 671F0
The insulin safety cards:
These cards can be ordered by contacting the local representative for Eli Lilly, Novo Nordisk and Sanofi insulin companies. Insulin safety cards are not available for animal insulins
How to use the insulin safety card:
Select the appropriate insulin safety card for the correct insulin AND device
Give to the patient and ask them to carry at all times and use it to check they have the correct insulin when receiving a prescription, when insulin is dispensed, or in situations when insulin is being given to them by another person
Advise the patient to destroy any old cards they have
Record that the card has been given. Relevant Read codes are:
Insulin passport given 8CE02
Insulin passport completed 8BAi.
Informed dissent not to carry insulin passport 8BAj.
If the correct insulin safety card is not available:
Give the NPSA generic insulin passport and complete the details for the insulin(s) and device prescribed