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Despite knowledge of accidents, opportunities for potassium ADE's persist in some US hospitals

From the August 28,1996 Issue

PROBLEM: Despite widespread coverage of potassium chloride-related deaths in professional journals, newsletters, and the lay press (ABC 20/20, August 23, 1996), some US hospitals still have not established necessary controls to optimize the safe administration of this drug. A close call last week at a children's hospital illustrates why hospitals must be proactive rather than reactive when addressing this issue. A pharmacist received a call from a pediatric nurse who wanted to know if there wer e smaller IV bags for 0.45% saline than 1000 mL. The pharmacist informed her that there were and asked why she wanted to know. The nurse stated that she had to give an IV medication and wanted to use the least expensive bag. The pharmacist told her that there was little difference between the costs of the various IV bags, and not enough to justify sending up a smaller bag specifically for her purpose. As the nurse was about to hang up she mentioned: "It's just that I have 20 mEq of potassium to give in 30 mL over one hour and don't want to waste all that fluid." Instant chaos!

The pharmacist asked who the potassium was for and was told that a surgical resident had written this order for a 23 day-old. A child of this size and age would ordinarily receive just 3 mEq of potassium per kg per day! The nurse was instructed not to hang the IV and to wait until the pharmacist called the surgical resident. Although the resident initially failed to see what the problem was, when told of the correct dose and the possible consequences of a 20 mEq dose of potassium given over one hour, he readily agreed to cancel the order and check with the pediatric attending physician regarding what dose of potassium, if any, should be given.

Administering 20 mEq of potassium most likely would have killed the child. The fact that the potential medication error was intercepted by the pharmacist is commendable, but the situation begs the bigger question of how this even came so close to being a serious adverse drug event. Obviously, the surgical resident was not completely familiar with fluid and electrolyte therapy in children. Still, that is probably not all that uncommon among non-pediatricians. The information was passed on to the Medical Director for Pediatrics, and that matter will be handled there.

How did the nurse happen to have 20 mEq of potassium? The answer is quite simple - she took it from another patient's medication drawer. For dehydrated pediatric patients, orders are commonly written at the hospital to "add 20 mEq of potassium to I V after child begins to urinate". The pharmacy in the hospital where this happened routinely sends vials of 20 mEq potassium chloride injection to the floor for such patients. Potassium injection is also readily available for dispensing from automated dispensing modules (in this case Pyxis), located near many of the pediatric nursing floors.

SAFE PRACTICE RECOMMENDATION: The pharmacy recently instituted a new potassium policy for this hospital. Potassium will not be kept as floor stock anywhere in the hospital except in the neonatal & pediatric intensive care unit Pyxis machines where s pecial packaging and controlled storage is used. Further, potassium will not be sent to the nursing floors for patient orders, and all potassium-containing IVs must be either manufacturer prepared or, when the desired concentration is not available commercially, pharmacy-prepared. A policy is being written that will specify exactly what amounts of potassium may be safely administered on the nursing floor. In addition, pediatric nursing will receive in-servicing on the policy and the safe administration of potassium.

Will any of this totally eliminate the possibility of potassium being administered in an incorrect, and possibly dangerous manner? Experience suggests that the answer to that is "no", but even if you can't stop the train at least you can drag your legs. Will this policy meet with some resistance from nurses who feel, and rightly so, that there are more and more restrictions to performing patient care? Yes, it probably will. However, any of us would be willing to suffer the slings and arrows of an angry professional if it means a patient, and particularly a young child, is a little safer. [D, N, P, Q, T]

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