High-risk medication alert: intravenous potassium chloride

Abstract

Patients have died in hospitals both in Australia and overseas after being mistakenly injected with potassium chloride instead of normal saline. In an effort to reduce the risks associated with the use of intravenous potassium chloride, the Australian Council for Safety and Quality in Health Care has issued a high-risk medication alert for intravenous potassium chloride. This alert contains recommendations for prescribing, storage, preparation and administration of intravenous potassium chloride.

Serious Inadequacies in High Alert Medication-Related Knowledge Among Pakistani Nurses: Findings of a Large, Multicenter, Cross-sectional Survey

“…Concentrated electrolyte solutions like KCl (15%), calcium chloride (CaCl 2 ), and hypertonic saline should not be administer via IV push due to greater risk of complications. Incorrect IV administration of KCl (15%) causes adverse events like arrhythmias and cardiac arrest leading to patient's death as documented in the previous studies (Reeve et al, 2005;Bonvin et al, 2009). Similarly, inappropriate administration of hypertonic saline cause phlebitis, extravasation injuries, and hypernatremia resulting in hypertensive emergencies especially in cardiac patients (Dillon et al, 2018).…”

Medication safety in acute care in Australia: where are we now? Part 2: a review of strategies and activities for improving medication safety 2002-2008

“…Incorrect IV administration of potassium chloride can potentially cause significant patient harm [ 39 ]. The Medication Safety Taskforce of the previous Safety and Quality Council recommended components to be included in guidelines for potassium chloride [ 40 ] and case studies from two Australian hospitals were developed and made available online.…”

Reducing the risk of harm from intravenous potassium: A multi-factorial approach in the haematology setting

“…The true incidence of potassium-related fatalities and incidents in the hospital setting is unknown; 11 however, examples of commonly reported errors and proposed solutions are described. Peripheral administration of a 40 mmol premixed bag.…”

“…A commonly reported error has been the inadvertent selection of a potassium ampoule instead of a sodium chloride 0.9% ampoule-classically described as a 'look-alike-sound-alike' error. 11 In this situation, the health-clinician inadvertently selects the incorrect ampoule (similar size and shape) and administers the potassium as a bolus injection, which can lead to patient harm. International case studies describing fatal outcomes have prompted changes to the storage of ampoules, for example the segregation of ampoules with a similar appearance to potassium.…”

“…To meet safety standards, many clinical areas have introduced premixed potassium infusions and accompanying guidelines to direct the safe administration of IV potassium. In Australia, this is now a routine practice in general wards; [9][10][11] however, haematology units have often been overlooked as standard infusions do not meet complex patient needs. 12 Patients with haematological conditions, as a result of treatments and subsequent complications, are prone to a serious and acute depletion of potassium that warrants large amounts of potassium needing to be replaced.…”