KCl deaths: Art imitates life

From the November 20, 1996 issue

On November 7th a med-surg nurse with a temporary assignment to work in the ER mixed up unlabeled syringes of saline and potassium chloride and nearly killed a patient by injecting KCl by IV push. This won't make the medication errors database because it happened on NBC-TV's ER. But another KCl error, sent to ISMP by USP on the very same day was all too real. The Arkansas State Board of Nursing is investigating two nurses who last month accidentally gave a 71-year-old man IV push KCl instead of IV furosemide. The patient arrested, was resuscitated, but died six hours later. Neither nurse had been previously involved in a serious error. Both have been suspended pending an investigation. ISMP is aware of over a dozen cases of mix-up between potassium and furosemide. Investigations by us indicate that some incidents may be the result of a mental slip which occurs when nurses mentally associate potassium excretion with furosemide administration and subsequently have potassium in mind and at hand while preparing what they believe to be furosemide whose mg dose overlaps with potassium's mEq dose. If needed, please call us for support to better control potassium chloride concentrate vials.