Executive Summary Checklist

Severe hypoglycemia (SH) causes significant morbidity and occasional mortality in hospitalized patients. The establishment of an effective program to reduce errors in the recognition and treatment of SH requires an implementation plan that includes the following actionable steps:

The Performance Gap

Hypoglycemia is a common problem for many patients with diabetes, and it can also occur in non-diabetics in a hospital setting.  . Mild episodes can cause unpleasant symptoms and disrupt daily activities. Severe hypoglycemia (SH) can result in disorientation and unusual behavior, and may be life-threatening. Frequent hypoglycemia is associated with increased morbidity, length of stay, and mortality. Hypoglycemia has been associated with mortality in the intensive care units \cite{Elliott_2012}. Moderate and SH are strongly associated with increased risk of death, especially from distributive shock \cite{2012}. This is by means of impairment of autonomic function, alteration of blood flow and composition, white cell activation, vasoconstriction, and the release of inflammatory mediators and cytokines \cite{Adler_2008},\cite{Wright_2008}. The prevalence of hypoglycemia (serum glucose <70 mg/dL) was reported as 5.7% of all point-of-care blood glucose (BG) tests in a 2009 survey of 575 hospitals.\cite{Swanson_2011}. The definition of SH (a low BG level that requires the assistance of another person for recovery), is a level <40 mg/dL, has been adopted as the level likely to cause harmin the hospital setting \cite{Schwartz_2007}. SH is a preventable harm. Early therapeutic management of mild hypoglycemia can prevent more SH episodes. In addition, literature showed that clinicians do not consistently adjust their patient’s anti-diabetic regimens appropriately following treatment of hypoglycemia, placing the patient at additional risk \cite{Boucai_2011},\cite{DiNardo_2006}.
Causative factors that may lead to the development of hypoglycemia for inpatients may include excessive insulin dose, inappropriate timing of insulin or anti-diabetes therapy, unaddressed antecedent hypoglycemia or changes in the nutritional regimen, creatinine clearance changes, or steroid dose (9)\cite{Deal_2011}. Failure of effective BG monitoring and communication between physicians, pharmacists and nurses can also contribute to the problem. The diverse nature of potential errors in the treatment of inpatients with SH supports the need for a decision-making model that can be used to predict and prevent SH episodes and improve overall patient safety and outcomes.
Closing the performance gap will require hospitals and healthcare systems to commit to action in the form of specific leadership, practice, and technology plans.

Leadership Plan

Practice Plan

Technology Plan

Suggested practices and technologies are limited to those proven to show benefit or are the only known technologies with  a  particular  capability.  As  other  options  may  exist,  please  send information  on  any  additional  technologies, along with appropriate evidence, to info@patientsafetymovement.org.