Hypoglycaemia simulation training to address serious untoward incidents in a hospital setting


Cornwall has a diabetes population of 28,000, with a high in-patient diabetes prevalence of 16.4%. Diabetes healthcare is increasing in complexity and, with changing team dynamics and restructuring of healthcare organisations, comes a need to provide high quality safe clinical practice in diabetes management. Cornwall Partnership NHS Foundation Trust's DISN team created a Hypoglycaemia Simulation Training programme following three Serious Untoward Incidents (SUIs) of hypoglycaemia, two of which resulted in deaths. The programme enabled teaching of the management of hypoglycaemia according to the Trust guideline within the ward situation, at the point of care. Following the session, participants undertake a structured team de-brief that analyses learning points, response to the event, team communication and working integration, appropriate and timely use of ward and hypoglycaemia resources. Open and interactive discussion provides feedback for development and any remedial measures are identified and actioned.


The hospital had experienced three hypoglycaemia management SUIs - despite an up-to-date Trust wide hypoglycaemia guideline, the introduction of hypoglycaemia ward boxes, regular face to face training and access to national e-learning modules. These educational methods alone appeared to be ineffective. Simulation training, widely used by the aviation industry, has received significant endorsement by the Department of Health and the General Medical Council and it was decided to develop a Hypoglycaemia Simulation module designed to be delivered at the POC. The idea was that challenging human factors in the work environment allows the multi-disciplinary team to learn together, improving performance, with consequent delivery of safer patient care, better outcomes and improved productivity.


To address failings in the clinical area following hypoglycaemia SUI and reduce their occurrence. Also, to improve management of hypoglycaemia within the hospital and develop effective multi-disciplinary teams.

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QiC Diabetes Winner 2016
Diabetes Team Initiative of the Year
Hypoglycaemia simulation training to address serious untoward incidents in a hospital setting
by Cornwall Partnership NHS Foundation Trust


Kim Bull

Job title:
Clinical Nurse Specialist Diabetes
Place of work:
Cornwall Partnership NHS Foundation Trust
01872 253104


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