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National Diabetes In-patient Audit - Harms

NaDIA-Harms is a year-round collection of four harms that can occur to diabetic inpatients in England.

This audit is part of the National Diabetes Audit Programme.


Latest Report

The 2020 NaDIA-Harms annual report was published on Thursday 8 July 2021. It details participation and the numbers of harms, based on the data collected between 1 May 2018 and 31 October 2020.

The 2019 NaDIA-Harms annual report was published in November 2020.

The first NaDIA-Harms report was published on Thursday 9 May 2019.


The Welsh government decided not to participate in the first year of the harms collection. Consequently, health services in Wales are not eligible to participate. We will inform all possible candidates as soon as there is a change in this situation.

2020 Participation

The NaDIA-Harms collection is continuing throughout 2020. We understand that some services will be unable to fully participate and there are no consequences for not entering data this year.

The audit plans to produce an annual report based on Harms occurring before October 31st. A final submission deadline for the annual report will be November 30th.

We would like to thank the services who have managed to continue submitting data in these difficult times.

Purpose of the collection

The objective of the harms collection is to reduce the rates of serious inpatient harms (severe hypoglycaemia, Diabetic ketoacidosis (DKA)/hyperosmolar hyperglycaemic state (HHS), and new foot ulcer) by collecting and providing regular feedback to hospital trusts to inform quality improvement work on a monthly basis.

All acute hospitals in England, with inpatients with diabetes are eligible to participate. If in doubt please contact us.

How to participate

  1. Identify an audit lead for your organisation or trust.
  2. Start data collection using the NaDIA-Harms Data Collection Form.
  3. Register all staff who will submit data by completing the NaDIA-Harms User Registration Form.
  4. Submit data using the secure online submission tool, the Clinical Audit Platform - this can only be done by staff once they are confirmed as registered.

Read the implementation guidance for full details of how to participate and submit data.

Harm specification

We have released guidance on harm specification questions within the NADIA data collection.

Hypoglycaemic Rescue 

‘Did the patient require injectable rescue treatment for an episode of hypoglycaemia starting more than 6 hours after admission?’

For the purpose of this audit an episode should be recorded only if subcutaneous and/or intravenous injected rescue treatment (glucagon, glucose) for severe hypoglycaemia was used.

For consistency and compatibility this harm is defined not by the measured blood glucose level but by the need to urgently counteract severe hypoglycaemic symptoms such as loss of consciousness, acute confusion or seizures with injected treatment. 

Rescue treatment would usually be intravenous glucose or subcutaneous/ /intramuscular/intravenous glucagon. 

For example, these treatments may be required if pre-meal insulin had been given but the meal had not been delivered resulting in severe hypoglycaemic (loss of consciousness, acute confusion, seizures etc due to a low blood glucose) requiring rescue treatment. 

Low blood glucose arising in patients receiving intravenous insulin infusions as well as intravenous glucose has led to some misunderstanding of ‘rescue treatment’. Intravenous glucose infusions should always run alongside continuous intravenous insulin and their use in this situation should not be considered ‘rescue treatment’ even when the CBG falls below 4.0 mmol/L provided that the patient has no severe hypoglycaemic symptoms. If, however, the person develops severe hypoglycaemic symptoms such as loss of consciousness, acute confusion or seizures during the infusion and require additional glucose or glucagon this would be considered ‘rescue treatment’.

Diabetic Keto Acidosis (DKA)

Was the patient diagnosed with new onset DKA more than 24 hours after admission?’

DKA requires three key features for diagnosis:

  • known diabetes or blood glucose over 11.0 mmol/l
  • Ketonaemia (blood ketones 3.0 mmol/l or more) or urine ketones 2+ or more
  • Acidosis with venous pH less than 7.3 or bicarbonate less than 15 mmol/l. 

For more on the definition of DKA please refer to the JBDS guidelines on the ABCD web site.

Hyperglycaemic Hyperosmolar State (HHS)

‘Was the patient diagnosed with new onset HHS more than 24 hours after admission?’

HHS has characteristic features used in its diagnosis:

  • Hypovolaemia
  • marked hyperglycaemia (blood glucose 30 mmol/l or more) without significant ketonaemia (blood ketones less than 3 mmol/l) or acidosis (venous pH 7.3 or more/bicarbonate 15 mmol/l or more)
  • Osmolality usually 320 mosmol/kg or more. 

For more on the definition of HHS please refer to the JBDS guidelines on the ABCD web site.

Diabetic foot ulcer

‘Was the patient diagnosed with a new onset foot ulcer more than 72 hours after admissions?’

The audit is not intended to collect reports of foot ulcers that are present on admission, or which develop within 3 days of admission. Grade 2+ Pressure sores on the foot that develop more than 72 hours after admission should be included. Deep tissue injury which has not progressed to skin ulceration is not included. Traumatic skin foot lesions and foot infections which arise during the admission are included.

When to collect data

The NaDIA-harms audit is a continuous data collection; you can enter data at any time but ideally harms should be entered in the same calendar month. If you miss the end of the month deadline, please enter the data as soon as possible.


Reports are now available under the ‘Submission Confirmation’ tab within the CAP data collection system. Please see ‘verifying nil submissions’ in the user documents for further details.

You can download all the data your trust has entered using the ‘extract’ function available under the ‘Reports’ tab. This will produce a CSV file which can be manipulated using Excel or equivalent software.

If you have any requirements or ideas for other reports, please get in touch via the links below.

Contact us

If you have any questions or would like to be added to our distribution list for the audit so that you receive updates directly, please contact the NaDIA team at

If you have registered to enter data, your details will have automatically been added to the distribution list.

Guidance for patients

Last edited: 7 September 2021 8:35 am