|
Despite knowledge of accidents, opportunities
for potassium ADE's persist in some US hospitals
Click here for printer friendly version
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]
|
|
