title: Examining the "Killer K" of Diabetic Ketoacidosis at a Tertiary Care Hospital: An Exploratory Study.
abstract: OBJECTIVE
  Hypokalemia, a frequently cited complication of diabetic ketoacidosis (DKA) treatment, can have critical implications, including arrhythmias and death. We assessed the prevalence of hypokalemia and its associated factors in patients with DKA at our tertiary-care centre and identified opportunities to improve care.
  
  
  METHODS
  We conducted a retrospective chart review to establish the prevalence of hypokalemia in patients diagnosed with DKA between July 2012 and July 2013. A focused root-cause analysis was subsequently performed to identify Canadian Diabetes Association DKA clinical practice guideline deviations and preventable errors that resulted in significant hypokalemia (K<3.3 mmol/L) during the first 48 hours of management. Clinical and management details were reviewed to determine the type, preventability and root cause(s) of each error.
  
  
  RESULTS
  We identified 40 cases of DKA during the study period. The overall prevalence of hypokalemia during DKA treatment was 38% (15/40), with 25% in type 1 and 56% in type 2 diabetes. Males were more likely to experience hypokalemia (87%), and 47% of hypokalemic incidents occurred in the first presentation of diabetes. All 10 cases of significant hypokalemia were reviewed. We identified 23 errors in 6 (60%) cases, of which 87% were deemed to be preventable. The most common errors were noncessation of insulin infusion during hypokalemia (60%), inadequate potassium supplementation (50%) and infrequent biochemical monitoring (50%).
  
  
  CONCLUSIONS
  Hypokalemia occurs frequently during acute DKA management and is often preventable. Our findings suggest that interventions targeted at enhancing awareness of guidelines may reduce hypokalemia rates.
authors.affiliation: University of Toronto, Toronto, Ontario, Canada; University of Ottawa, Ottawa, Ontario, Canada.
authors.forename: Bertha
authors.initials: B
authors.lastname: Wong
authors.affiliation: University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Amy
authors.initials: A
authors.lastname: Cheng
authors.affiliation: University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, Toronto, Ontario, Canada.
authors.forename: Catherine
authors.initials: C
authors.lastname: Yu
authors.affiliation: University of Toronto, Toronto, Ontario, Canada; St. Michael's Hospital, Toronto, Ontario, Canada. Electronic address: goguenj@smh.ca.
authors.forename: Jeannette
authors.initials: J
authors.lastname: Goguen
mesh_terms: D016883:Diabetic Ketoacidosis / Q000150:complications* / Q000188:drug therapy; D005260:Female; D006801:Humans; D007008:Hypokalemia / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology*; D007328:Insulin / Q000009:adverse effects / Q000627:therapeutic use; D008297:Male; D019300:Medical Errors; D011188:Potassium / Q000008:administration & dosage / Q000627:therapeutic use; D015995:Prevalence; D012189:Retrospective Studies; D062606:Tertiary Care Centers
chemical_list: D007328:Insulin; D011188:Potassium
keywords: acidocétose diabétique; amélioration de la qualité; diabetic ketoacidosis; hyperglycemic emergency; hypokalemia; hypokaliémie; patient safety; quality improvement; sécurité du patient; urgence hyperglycémique