Serious harm from inpatient hypoglycaemia: a survey of hospitals in the UK.

Aim: To estimate the incidence of serious harm to inpatients with diabetes from hypoglycaemia.

Method: An anonymised questionnaire was e-mailed to lead organisers at the 142 acute NHS Trusts that contributed to the National Diabetes Inpatient Audit 2012. Each diabetes team was asked collectively to recall and report any serious adverse events from inpatient hypoglycaemia in the previous year. A total of 83 Trusts agreed to participate. Serious harm was defined as death, a cardiac or cerebral event or a fall resulting in permanent physical injury or fracture.

Results: A total of 41 Trusts returned the survey. Of these, only 28 (68.3%) were confident that robust methods existed in their Trust to ensure all such events were reported, and only 23 (56.1%) were confident that all such events were reported to the diabetes team. Despite these reporting concerns, the retrospective nature of the survey and the reliance on recall, 12 serious adverse events were reported from nine trusts: three deaths; two cases of permanent cerebral damage; two successfully resuscitated cardiac arrests; three seizures; and two undefined events. Insulin therapy was implicated in 10 events. Importantly, three events with two deaths occurred in patients who had received insulin/dextrose to correct hyperkalaemia; only one of whom had diabetes.

Conclusions: An alarming number of serious adverse events was reported: 12 serious adverse events with three deaths over a 1-year period in 41 Trusts. This may be the tip of the iceberg, considering the potential under-reporting. Robust reporting mechanisms are required to determine the full extent of this serious preventable harm.