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Abstract Background: Iron deficiency is very common in patients admitted to hospital. Its management is changing with new insights into iron absorption and therapeutic options. Aims: The aims of this study were to develop guidelines for the correction of iron deficiency in patients admitted to hospital and to compare these with current practice. Methods: Based on current published evidence, guidelines were developed. All patients in whom iron deficiency was detected during hospital admission over a 2.5 year period were retrospectively studied. Their management was compared with that of the guidelines developed. Results: Three clinical scenarios were identified—(A) urgent attention to haemoglobin required: blood transfusion followed by i.v. iron recommended, (B) Semiurgent iron repletion: i.v. iron recommended and (C) non-urgent iron repletion: oral or i.v. repletion recommended. A total of 119 patients was identified, age 18–99 (median 77) years, 29% men, and haemoglobin 33–130 (87) g/L. Of 66 given blood transfusion, 17 had subsequent i.v. iron, 25 oral iron and 24 no other form of iron repletion. Of the other 53, nine had i.v. iron, 32 oral iron and 12 had no treatment. Fifty-five per cent of patients were managed according to the proposed guidelines and this occurred less frequently (9%) in those presenting with cardiovascular problems than in those with anaemia, gastrointestinal bleeding or other medical problems (all >60%; P < 0.0001, Fisher's exact test). Conclusion: Current management is haphazard, with underutilization of i.v. iron and failure to initiate any regimen for iron repletion being common. It may be time for a change in approach to repletion of iron in ill patients.