Hypoglycaemia in hospital: a re‐audit and root cause analysis using a hypoglycaemic events reporting system

Abstract

AbstractHypoglycaemia frequently affects hospitalised patients with diabetes mellitus and most events are both predictable and preventable. A previous audit demonstrated that the documentation of hypoglycaemic events in hospitalised patients was not only incomplete but sometimes non‐existent. We therefore devised a Hypoglycaemic Events Reporting System (HERS) to enable us to re‐audit the management of hypoglycaemic events and to perform root cause analyses.Any member of staff providing treatment for hypoglycaemia documented each event on the paper format of HERS. This was used to enable retrieval of clinical notes for a retrospective audit and root cause analyses.Seventy‐nine patient events were reported on HERS over a one‐year period. This occurred in 56 patients aged 21–92 years. The majority of events were mild, asymptomatic and single events that occurred at night in patients on insulin. Based on documented evidence, all patient events received initial treatment according to guidelines, 90% had a 15‐minute capillary blood glucose (CBG) check, 48% had a 20–40g carbohydrate snack, 54% had a repeat 45–60 minute CBG check, 17% had evidence of a doctor being informed and 49% had the event documented in the notes. Root cause analyses demonstrated common identifiable risk factors/causes and that 46% of patient events were deemed preventable.This audit has demonstrated good compliance with the guidelines for the treatment of hypoglycaemia in hospital with room for improvement, especially around documentation. The HERS improved data quality and quantity for audit purposes. All hypoglycaemic events should be evaluated in terms of risk management and preventative strategies. Copyright © 2013 John Wiley & Sons.