Preventing Potassium Problems Permanently: Eliminating Concentrated Potassium Chloride Errors

Abstract

ABSTRACTBackgroundIV potassium chloride is potentially one of the most dangerous medications, and accidental bolus administration of concentrated potassium chloride is well documented. In 2001, The Alfred identified this as a key patient safety priority.AimTo identify potential sources of error associated with concentrated potassium chloride and introduce an effective and practical risk reduction strategy to prevent inadvertent accidental administration.MethodRoot‐cause analysis was used to identify factors that contributed to a serious incident involving inadvertent administration of concentrated potassium. The application of a well‐recognised error prevention framework facilitated the development and implementation of a risk‐reduction strategy. This involved the elimination of concentrated potassium chloride ampoules from hospital wards, their substitution with clinically appropriate pre‐mixed potassium chloride preparations, and standardisation of potassium chloride prescribing units.ResultsAt The Alfred, concentrated potassium chloride ampoules were removed from all general wards and substituted with a commercially prepared solution containing potassium chloride 30 mmol/1000 mL. A pre‐mixed solution containing 10 mmol/100 mL, appropriate for use in fluid‐restricted patients, was developed and introduced through collaboration with another major teaching hospital and a manufacturer. All potassium chloride doses are now prescribed in millimoles, not grams.ConclusionThe Alfred's potassium chloride safety strategy has been effective in reducing the risks associated with inadvertent administration of concentrated potassium, through the elimination of concentrated potassium from all general wards and the development and introduction of an alternative potassium formulation that is appropriate for use in fluid‐restricted patients.