Hospital Harm - Severe Hypoglycemia

The measure assesses the proportion of inpatient hospitalizations for patients age 18 and older who were administered at least one hypoglycemic medication during their hospitalization and consequently experience a severe hypoglycemic event during the encounter

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The goal of this eCQM is to improve patient safety and prevent the adverse drug event severe hypoglycemia (blood glucose (BG) <40 milligrams per deciliter [mg/dL]). The measure captures severe hypoglycemia in patients who are at risk. At risk patients are defined by the measure as those who receive a hypoglycemic medication during their inpatient hospitalization.
While safety events are generally rare, hypoglycemia (BG ≤ 70 mg/dL) is one of the more frequently observed safety events. In a study published by the Office of the Inspector General (2022), adverse drug events represented 43% of all adverse events in hospitals among Medicare patients in 2018, with hypoglycemia among the top 5 most commonly occurring adverse drug events.
Additional studies indicate that severe hypoglycemia occurs in 2 to 5% of hospitalized patients with diabetes mellitus (Santos et al., 2020). Rodrick and colleagues (2024) reported that approximately 4.7% of adult patients insured by Medicare experienced a hypoglycemic event in both 2021 and 2022.
Inpatient hypoglycemia can be life-threatening and is associated with longer hospital stays and increased medical costs. Patients who experience a hypoglycemic event have, on average, a 4.1 day longer length of stay in the hospital (Cruz, 2020).
Hypoglycemic events within an inpatient setting are largely avoidable by monitoring the use of medications and nutritional status. The National Quality Forum (2011) has identified medication errors as one of its Serious Reportable Events (SREs) or “never events” and included over- or under-dosing of the hypoglycemic medication insulin as a specific example. SREs are defined as serious and harmful clinical events that are largely preventable.
Recent studies show that rates of severe hypoglycemia vary across hospitals, suggesting opportunities for improved care (Santos et al., 2020). Hospitals’ efforts to reduce incidents of hypoglycemia have been shown to improve patient outcomes and reduce costs (Shelton, 2021; Mattathil, 2023). For example, studies have demonstrated that surveillance of glycemic outliers and interdisciplinary approaches to glycemic management can reduce or prevent hypoglycemic events (American Diabetes Association, 2025).

From Section 16, Diabetes Care in the Hospital in the Standards of Medical Care in Diabetes by the American Diabetes Association (2025):

 

  
16.12 A hypoglycemia management surveillance protocol should be adopted by all health systems. A plan for identifying, treating, and preventing hypoglycemia should be established for each individual. Episodes of hypoglycemia in the hospital should be documented in the health record and tracked to inform quality improvement.
 
 

  
16.13 Treatment plans should be reviewed and changed as necessary to prevent hypoglycemia and recurrent hypoglycemia when a BG value of <70 mg/dL (3.9 millimoles per liter [mmol/L]) is documented.
 

A standardized hospital-wide, nurse-initiated hypoglycemia treatment protocol should be in place to immediately address BG levels of <70 mg/dL (3.9 mmol/L). In addition, individualized plans for preventing and treating hypoglycemia for each person should also be developed. An American Diabetes Association (ADA) consensus statement recommends that an individual's treatment plan be reviewed any time a BG value of <70 mg/dL (3.9 mmol/L) occurs, as this level often predict subsequent level 3 hypoglycemia. Episodes of hypoglycemia in the hospital should be documented in the EHR and tracked. A key strategy is embedding hypoglycemia treatment into all insulin and insulin infusion orders.
From the Endocrine Society clinical practice guideline on the Management of Hyperglycemia in Hospitalized Patients in Non-critical Care Setting (Korytkowski et al., 2022) as it relates to patients at high risk of hypoglycemia:

 

  
Recommendation 1.1 In adults with insulin-treated diabetes hospitalized for noncritical illness who are at high risk of hypoglycemia, we suggest the use of real-time continuous glucose monitoring (CGM) with confirmatory bedside point-of-care blood glucose (POC-BG) monitoring for adjustments in insulin dosing rather than POC-BG testing alone in hospital settings where resources and training are available.
 
 

  
Recommendation 2.1 Management of patients with glucocorticoid (GC)-associated hyperglycemia requires ongoing BG monitoring with adjustment of insulin dosing. All therapies require safeguards to avoid hypoglycemia when doses of GCs are tapered or abruptly discontinued.
 
 

  
Recommendation 10.1 In adults with no prior history of diabetes hospitalized for noncritical illness with hyperglycemia [defined as BG > 140 mg/dL (7.8 mmol/L)] during hospitalization, we suggest initial therapy with correctional insulin over scheduled insulin therapy (defined as basal or basal/bolus insulin) to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For patients with persistent hyperglycemia [≥2 POC-BG measurements ≥ 180 mg/dL (≥10.0 mmol/L) in a 24-hour period on correctional insulin alone], we suggest the addition of scheduled insulin therapy.
 
 

  
Recommendation 10.2 In adults with diabetes treated with diet or noninsulin diabetes medications prior to admission, we suggest initial therapy with correctional insulin or scheduled insulin therapy to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L). For hospitalized adults started on correctional insulin alone and with persistent hyperglycemia [≥2 POC-BG measurements ≥ 180 mg/dL in a 24-hour period (≥10.0 mmol/L)], we suggest addition of scheduled insulin therapy. We suggest initiation of scheduled insulin therapy for patients with confirmed admission BG ≥ 180 mg/dL (≥10.0 mmol/L).
 
 

  
Recommendation 10.3 In adults with insulin-treated diabetes prior to admission who are hospitalized for noncritical illness, we recommend continuation of the scheduled insulin regimen modified for nutritional status and severity of illness to maintain glucose targets in the range of 100 to 180 mg/dL (5.6 to 10.0 mmol/L).
 

Remarks
Reductions in the dose of basal insulin (by 10% to 20%) at time of hospitalization may be required for patients on basal heavy insulin regimens (defined as doses of basal insulin ≥ 0.6 to 1.0 units/kg/day), in which basal insulin is being used inappropriately to cover meal-related excursions in BG.

Decreased score indicates improvement

Reference Type: Citation

Reference Text: 
American Diabetes Association Professional Practice Committee. (2025). 16. Diabetes care in the hospital: Standards of medical care in diabetes - 2025. Diabetes Care, 47(Supplement_1), S321–S334. https://doi.org/10.2337/dc24-S016

Reference Type: Citation

Reference Text: 
Cruz, P. (2020). Inpatient hypoglycemia: The challenge remains. Journal of Diabetes Science and Technology, 14(3), 560-566. doi:10.1177/1932296820918540

Reference Type: Citation

Reference Text: 
Korytkowski, M. T., Muniyappa, R., Antinori-Lent, K., Donihi, A. C., Drincic, A. T., Hirsch, I. B., Luger, A., McDonnell, M. E., Murad, M. H., Nielsen, C., Pegg, C., Rushakoff, R. J., Santesso, N., & Umpierrez, G. E. (2022). Management of hyperglycemia in hospitalized adult patients in non-critical care settings: An Endocrine Society clinical practice guideline, The Journal of Clinical Endocrinology & Metabolism, 107(8), 2101–2128. https://doi.org/10.1210/clinem/dgac278

Reference Type: Citation

Reference Text: 
Mattathil, R. (2023). Hypoglycemia management using a bundled care approach: A quality improvement project. Journal of Nursing Care Quality, 38(d), 141–145. https://doi.org/10.1097/NCQ.0000000000000670

Reference Type: Citation

Reference Text: 
National Quality Forum. (2011). Serious reportable events in healthcare–2011 update: A consensus report. https://doh.wa.gov/sites/default/files/legacy/Documents/2900//NQF2011Update.pdf

Reference Type: Citation

Reference Text: 
Rodrick, D., Timashenka, A., & Umscheid C. (2024). Adverse events among in-hospital Medicare patients in 2021 and 2022: Preliminary report. (AHRQ Publication No. 24-0084). Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/quality-measures/qsrs/qsrs-2021-2022-adverse-event-data-report-nov-rev.pdf

Reference Type: Citation

Reference Text: 
Santos, C. A. Q., Conover, C., Shehab, N., Geller, A. I., Guerra, Y. S., Kramer, H., Kosacz, N. M., Zhang, H., Budnitz, D. S., & Trick, W. E. (2020). Electronic measurement of a clinical quality measure for inpatient hypoglycemic events: A multicenter validation study. Medical Care, 58(10):927-933. doi:10.1097/MLR.0000000000001398

Reference Type: Citation

Reference Text: 
Shelton, C., Demidowich, A.P., Motevalli, M., Sokolinsky, S., MacKay, P., Tucket, C., Abundo, C., Peters, E., Gooding, R., Hackett, M., Wedler, J., Alexander, L. A., Barry, L., Flynn, M., Rios, P., Fulda, C. L., Young, M.F., Kahl, B., Pummer, E., Mathioudakis, N. N., Sidhaye, A., Howell, E.E., Rotello, L., & Zilbermint, M. (2021). Retrospective quality improvement study of insulin-induced hypoglycemia and implementation of hospital-wide initiatives. Journal of Diabetes Science and Technology, 15(4), 733-740. https://doi.org/10.1177/19322968211008513

Reference Type: Citation

Reference Text: 
U.S. Department of Health and Human Services, Office of Inspector General Adverse Events in Hospitals. (2022). A quarter of Medicare patients experienced harm in October 2018. https://oig.hhs.gov/oei/reports/OEI-06-18-00400.asp

Inpatient hospitalizations: Includes time in the emergency department and/or in observation status when the transition between discharge from these encounters and admission to the inpatient encounter are one hour or less.
A severe hypoglycemic event (harm) is defined as a laboratory or POC test for glucose with a result less than 40 mg/dL, where a hypoglycemic medication was given within the 24 hours prior to the start of the low glucose event (i.e., glucose result less than 40 mg/dL) and administered during the encounter (including emergency department and observation stays contiguous with the admission). The 24-hour timeframe extends from the end of the medication administration to the time of the glucose test.
The measure does not count a severe hypoglycemic event (harm) in the numerator if there is a repeat test for glucose with a result greater than 80 mg/dL within five minutes of this initial low glucose test. The purpose of the repeat test within 5 minutes is to eliminate false positives that can occur in POC testing. The 5-minute timeframe extends from the start of the severe hypoglycemic test to the time of the repeat hypoglycemic test.

The measure is using milligrams per deciliter (mg/dL) as the unit of measurement for glucose results. Millimoles per liter (mmol/L) should be converted to mg/dL for reporting this measure.
Glucose levels are determined by laboratory or POC tests, including capillary/glucometer BG tests, and by interstitial fluid specimens from continuous glucose monitors. Glucose test results from urine specimens are not considered.
This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.
This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Inpatient hospitalizations that end during the measurement period for patients age 18 and older and at least one hypoglycemic medication administration starts during the encounter

Equals Initial Population

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Inpatient hospitalizations where a severe hypoglycemic event occurred during the encounter. A severe hypoglycemic event is:

 

  
A glucose test with a result less than 40 mg/dL
 

AND

 

  
A hypoglycemic medication was administered within 24 hours before the start of the severe hypoglycemic event (i.e., the glucose test with a result less than 40 mg/dL)
 

AND

 

  
There was no subsequent repeat test for glucose with a result greater than 80 mg/dL within five minutes or less from the start of the initial glucose test with a result less than 40 mg/dL
 

Only one qualifying severe hypoglycemic event is counted in the numerator, and only one severe hypoglycemic event is counted per hospitalization.
The 24-hour and 5-minute timeframes are based on the time the glucose was drawn, as this reflects the time the patient was experiencing that specific glucose level.

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex