Ahsiyah Bibi

1. 1. delayed treatment of high potassium

   “When reviewing Mrs. [name redacted] at 02:14 sic not have the results from an arterial blood gas performed by the nursing team at 01:52 which demonstrated high potassium therefore treatment for high potassium was not commenced until approximately 04:00 when the high potassium had been identified. It was the evidence of Han hat from time to time the hard copy blood gas results do get separated from the records and if the Clinician doesn't know the test has been undertaken they will have no reason to go and”

2. 2. insulin dosing error causing overdose

   “At04:00 a drug error was made in the prescribing and dispensing of Actrapid insulin for hyperkalaemia: Mrs. [name redacted] was prescribed a 50 unit dose instead of a 10 unit dose, the error was identified when she had received 20 units and the infusion was stopped. The evidence of il HE who prescribed the insulin was she knew the Trust's protocol and standard treatment to be a dose of 10 units but made a mistake. It appears from investigations carried out by that the two members of the nursing staff who”

3. 3. lack of system to prevent repeat insulin dosing errors and missing blood gas results

   “HE cvidence was that although he has investigated the insulin prescribing error and it has been discussed with the individuals involved there has not been a Trust wide review of the risks of this occurring again and consideration of a system to reduce the risk of error. The problem of missing blood gas results was identified by not considered for further action within the department or across the Trust.”

No published response was found on judiciary.uk.