In the circumstances it is my statutory to report to you. When reviewing Mrs. Bibi at 02:14 did not have 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 approximatelv 04.00 when the high potassium had been identified: It was the evidence of Jand that 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 source the results. At 04.00 a drug error was made in the prescribing and dispensing of Actrapid insulin for hyperkalaemia: Mrs. Bibi was prescribed a 50 unit dose instead ofa 10 unit dose,the error was identified when she had received 20 units and the infusion was stopped: The evidence ofl Iwho prescribed the Insulin was she knew the Trust'$ 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 dispensed the dose did not check the dose Professor Hanif,Consultant in Diabetes,gave independent expert evidence that in his view there Kidney the duty-the is a risk of inappropriate prescribing of insulin in the management of hyperkalaemia because clinicians are more commonly called upon to prescribed a 50 unit does for Hyperglycaemia. Therefore in his opinion a system is required to avoid error in cases of hyperkalaemia_ agreed that the fact she more commonly prescribes a 50 unit does of insulin for hyperglycaemia probably did explain her error. evidence 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 put not considered for further action within the department or across the Trust: