Background/Introduction Insulin administration errors represent an important clinical issue; the NHS national patient safety agency issued an alert in 2011 following a review of incidents involving insulin, and the 2016 national diabetes audit reported that errors are observed in 46% of adult patients treated with insulin. Inpatient insulin omissions can result in serious harm and prolonged hospital stays.

Aim(s)/Objectives The aims of our project was threefold, to review the prevalence of insulin omissions among diabetes inpatients at Medway Hospital, to identify the system errors leading to the omissions and then to implement cost-effective interventions to reduce the incidence by 50%.

Methods We retrospectively reviewed all insulin-treated diabetic patient notes on 4 wards over 3 weeks to ascertain baseline levels of insulin omissions. We then introduced quality improvement measures aimed at reducing insulin omissions: ‘posters informing ward-staff about insulin omissions’and a ‘clinical reporting pathway for insulin errors’. Data was collected prospectively fol-lowing each intervention. Results were analysed using the Mann-Whitney U test and compared to omissions data from a control ward.

Results Baseline data showed a total of 32 omissions. Following the interventions, there was a statistically significant 81% decrease in insulin omissions from 2.67 to 0.5 omissions per ward/week (p<0.0001). The control showed no statistically significant reduc-tion (p=0.117).

Discussion/Conclusion We showed that by introducing quality improvement measures at Medway, a significant reduction in insulin omissions was possible, reducing patient risks. Similar measures could be adapted by management for use in other hospitals. Increasing awareness of the importance of timely insulin administration through pathways such as posters/educational reminders is an effective and inexpensive tool for reducing inappropriate insulin omission rates.