​​​​At one facility, over a few months several incidents occurred involving patients in diabetic ketoacidosis (DKA), a life-threatening complication in which too much acid (ketones) builds up in the blood, in both the emergency department and acute care. The root cause analysis team assembled a diabetes task force to address the causes and concerns around care of diabetic patients and those in DKA. The task force, consisting of registered nurse supervisors, risk managers, the directors of Information Technology and acute care services, a diabetes educator, and the ED medical director, met over six months and implemented changes, including reviewing, revising, and creating new diabetes order sets; reviewing, revising, and creating new policies; and educating nurses and physicians of these changes. As a result of these collaborative improvements and other task force initiatives, no new incidents have occurred in the management of diabetes and DKA.​