Background: Hypoglycemia is a serious medical condition that can lead to adverse patient outcomes, including mortality and increased length of stay. As in-patient hypoglycemia is often iatrogenic, every effort should be taken to avoid its occurrence from a systems-based perspective.
Purpose: Memorial Hermann Hospital (MHH) has higher rates of inpatient hypoglycemia when compared to similar large academic institutions. This prompted our institution to perform root cause analysis and implement interventions with PDSA cycles to decrease rates of inpatient hypoglycemia. Reducing these rates is essential for improving patient safety and outcomes.
Description: Data on all episodes of hypoglycemia was recorded from patients on medicine and intermediate medical care unit (IMU) floors (June 2023 – November 2025) and collected from a central dashboard. Data underwent individual chart review to elucidate root cause. Our pilot data demonstrated the following risk factors categories: “NPO” status, tube feeding, type 1 diabetes mellitus, renal dysfunction (acute kidney injury or chronic kidney disease), and poor PO intake. Additionally, the majority of cases occurred on medicine teaching teams. After performing a stakeholder analysis and payoff matrix, interventions were designed.In April 2024, a pilot intervention was implemented as PDSA cycle 1, which involved sending an email to any team with a patient experiencing hypoglycemia, requesting feedback on why they believe the incident occurred and what changes could have prevented the episode. In October 2024, MHH underwent a transition in electronic medical record (EMR) system from Care4 to Epic with new insulin order sets, special alert systems, and ease of communication via Epic chat. As our second intervention and PDSA cycle 2, our team worked alongside endocrine faculty to design insulin and hypoglycemia order sets. Data on the incidence of hypoglycemia episodes was collected to assess the impact of these changes. In October 2025, a third intervention was implemented as PDSA cycle 3 which focused on resident education to target the higher rates of hypoglycemia on medicine teaching teams. This intervention involved creating a tip sheet resource on insulin dosing and hypoglycemia prevention which was disseminated to resident teaching teams via email, postings in team rooms, and presentations during monthly Introduction to Wards sessions. The incidence of hypoglycemia from patients on resident teaching teams is being monitored from October 2025 – March 2026 to assess the impact of the this intervention.
Conclusions: From June 2023 to March 2024, the baseline rate of inpatient hypoglycemia was 4.3 patients per month. After PDSA cycle 1, April 2024 to August 2024, the rate decreased to 3.0 patients per month, suggesting a reduction in inpatient hypoglycemia at MHH. After PDSA cycle 2, from November 2024-August 2025, the inpatient hypoglycemia rate was 3.5 patients per month, indicating retained improvement from baseline rate but possibly reflecting an adjustment period to a large systems-based modification with the change in EMR system. Data collection fro PDSA cycle 3, from October 2025 – April 2026 will further elucidate the impact of the educational intervention on the hypoglycemia rate on resident teaching teams.