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

Barras, Michael; Moore, Diana; Pocock, Daniel; Sweedman, Myles; Wilkinson, Cathy; Taylor, Kerry; Morton, James

doi:10.1177/1078155213504443

Cited by 7 publications

(16 citation statements)

References 24 publications

(44 reference statements)

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“… 44 , 60 The remaining 38 studies (83%) 32 – 34 , 36 – 40 , 42 , 45 – 58 , 61 – 66 , 68 – 76 applied an observational study design without large magnitude of effect, which is why they were graded as low quality. Controlled low-quality studies (n = 31) applied variable designs: simulation studies (n = 11) 32 – 34 , 36 – 39 , 49 , 53 , 57 , 66 ; observational reviews of drug charts, medication orders, or patient records (n = 11) 45 – 47 , 51 , 52 , 68 – 70 , 74 – 76 ; studies combining multiple methods (n = 4) 56 , 58 , 61 , 72 ; analyses of medication error or adverse drug event data (n = 3) 40 , 42 , 55 ; and analyses of infusion concentrations (n = 2). 48 , 50 Some low-quality studies (n = 7) 54 , 62 – 65 , 71 , 73 used an uncontrolled study design.…”

Section: Resultsmentioning

confidence: 99%

“…There was a lot of variations between the error detection methods used, which makes it difficult to compare results between the studies. Measures quite similar to medication errors, such as adverse drug events and clinical incidents (n = 5), 43,[58][59][60][61] potentially prevented medication errors (n = 4), [62][63][64][65] and serious medication errors (n = 2) 39,67 were used in 11 studies (24%). Time to task completion appeared in 12 studies, 34,[36][37][38][39]47,49,53,[55][56][57][58] and it was a commonly used measure especially in simulation studies (n = 9).…”

Section: Characteristics and Main Outcomes Of Included Studies (N = 46)mentioning

confidence: 99%

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Systemic Defenses to Prevent Intravenous Medication Errors in Hospitals: A Systematic Review

et al. 2021

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Section: Resultsmentioning

confidence: 99%

Section: Characteristics and Main Outcomes Of Included Studies (N = 46)mentioning

confidence: 99%

Systemic Defenses to Prevent Intravenous Medication Errors in Hospitals: A Systematic Review

et al. 2021

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“…The inadvertent administration of higher doses of KCl due to miscalculation is a substantial concern. There is greater concern in countries in which prediluted formulations of KCl have not been mass-produced, and in countries where undiluted ampules are used when prediluted formulations matched to a prescription are unavailable 1 2…”

Section: Introductionmentioning

confidence: 99%

Improving the safety of high-concentration potassium chloride injection

ナカタニ¹,

Nakagami-Yamaguchi²,

Shinoda

et al. 2019

BMJ Open Qual

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ObjectivesSerious adverse effects, including arrhythmia and cardiac arrest, result from rapid intravenous high concentration of potassium chloride (KCl). We aimed to eliminate prescription of undiluted KCl and encourage dilution of KCl to 400 mEq/L and 40 mEq/L in the intensive care units (ICUs) and general and outpatient departments, respectively.MethodsBefore the first intervention, we collected data regarding high-concentration KCl and interviewed representatives of physicians prescribing high-concentration KCl. Based on the guidelines in other countries on safely used concentrations of KCl (400 mEq/L), we negotiated with physicians to dilute KCl below 400 mEq/L. In the first intervention, we made rules based on surveys above. In the second intervention, we revised the rules based on opinions from physicians and pharmacists and investigated the change in the number of prescriptions of KCl concentration in each department. Continuing efforts with the safety manager ensured compliance of the rules by physicians and nurses in all departments.ResultsAfter the first and second interventions, prescriptions for undiluted KCl in ICUs and general wards were eliminated (median=0). Prescriptions for <400 mEq/L KCl increased to 110 (median) after the first intervention and to 137 (median) after the second. In the general ward, 7 months after the first intervention, prescriptions for <400 mEq/L KCl had not increased. Compliance with our rules was high, and more than 72% of physicians and nurses were aware of the rules.ConclusionsThe rules for administration of high-dose KCl successfully eliminated prescription of undiluted KCl, which was maintained using two plan-do-study-act cycles. Our intervention process could be useful in countries where prediluted formulations are unavailable or where prescriptions are not matched and undiluted ampules are used.

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“…O potássio, mesmo diluído pode causar danos ao paciente, e é comum a ocorrência de reações relacionadas à infusão, como evidenciado por outros estudos. 28,29 O potássio para infusão por via periférica, deve estar diluído preferencialmente a uma taxa > 40 mEq/L e a velocidade de infusão não exceder 10 mEq/hora. 30 Embora o potássio estivesse prescrito na faixa adequada de diluição e velocidade de infusão consideradas seguras, no nosso estudo, não foi possível recuperar informações quanto ao cumprimento da prescrição no momento da administração.…”

Section: Rbfhssunclassified

Adverse drug events: description of an active search process in a teaching hospital of the Sentinela Network

Nogueira¹,

Silva²,

Provin³

et al. 2021

Rev Bras Farm Hosp Serv Saude

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Objective: To describe the implementation of an active search service for adverse drug events (ADE) in a teaching hospital in the Midwest region of Brazil. Method: Observational sectional study conducted at the Pharmacovigilance Service in a University hospital in the Midwest Region of Brazil, from March to August/2019. All patients admitted to a medical clinic unit were included and those who did not find medical records were excluded. A work process structured in six stages was elaborated: 1) elaboration of a list of triggers through literature review; 2) elaboration of a list of patients whose previously selected triggers appeared; 3) visiting the wards and reviewing medical records; 4) validation of ADE; 5) notification of ADE to Agência Nacional de Vigilância Sanitária; 6) registration of information in databases. Results: The Positive Predictive Value (PPV) of each tracker was calculated individually and globally. The relative and absolute frequency of ADE was calculated as to the type, description and the drug involved. A total of 479 searches were made in the period and the frequency of ADE was 7.48%. The global triggers PPV was 0.04. The trigger with the best performance was promethazine (1.00), followed by the Activated Partial Thromboplastin Time (0.67). Regarding the identified ADE, it was observed that most of the time, 24.14% were related to infusion reactions. It was observed that 53.85% of the drugs involved in ADE were high alert medications. Conclusion: It was observed that the implementation of an active search service for ADE in hospitals that do not have the support of an electronic medical record system is feasible to be performed. It was also observed a high frequency of ADE and that the active search guided by triggers allows to identify events that otherwise could not be identified.

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

Abstract: A multi-factorial approach to the safe prescribing, dispensing and administration of intravenous potassium has reduced the potential for patient harm in the haematology setting.

Cited by 7 publications

References 24 publications

Systemic Defenses to Prevent Intravenous Medication Errors in Hospitals: A Systematic Review

Systemic Defenses to Prevent Intravenous Medication Errors in Hospitals: A Systematic Review

Improving the safety of high-concentration potassium chloride injection

Adverse drug events: description of an active search process in a teaching hospital of the Sentinela Network

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