ABSTRACT
This chapter presents a case study of a 90-year-old woman who has been brought into the Emergency Department as a priority call. The patient has suffered from iatrogenic hypoglycaemia due to an incorrectly prescribed insulin/dextrose infusion for hyperkalaemia. The assessing doctor correctly recognised that this patient was hyperkalaemic from an acute kidney injury and prescribed an insulin/dextrose infusion. The case was referred up to the senior doctor and nurse in real time to review the patient, prevent further harm, support those involved and gather information. All steps taken to correct or mitigate error should be documented in the patient record. When an error occurs, there is a duty to inform the patient and their family as soon as it is practical, apologise and explain why it may have happened and the steps taken to mitigate this. For this case, an incident form (Datix) should be filled out in real time.
