Medication Errors
Keep close tabs on your KCl
Potassium chloride often the culprit in medication errors
Take special precautions to keep concentrated potassium chloride (KCl) off shelves in nurses' units and away from bedsides. Five to 10 patients die every year in the United States when they are accidentally injected with the electrolyte; others go into cardiac arrest and suffer brain damage. Undiluted KCl is used to execute death row prisoners.
KCl should not sit available outside the pharmacy unless appropriate safeguards are in place. It is the drug most frequently implicated in medication errors investigated by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations. In all cases, a contributing factor is the availability of concentrated KCl on the nursing unit where it is mistaken for some other medication, primarily due to similarities in packaging and labeling. Most often KCl is mistaken for saline, heparin, or furosemide (Lasix). The medication is frequently prescribed in trace amounts. In 1991, after 40 to 50 deaths were attributed to the electrolyte, the Food and Drug Administration required distinctive black tops and new labels on all KCl vials. (See picture of black-topped KCl vial, p. 102.)
Despite efforts to train practitioners on its appropriate administration, as well as stricter and more distinct labeling and packaging requirements, patient injuries and deaths continue to occur. To counter those, hospitals have developed guidelines restricting the number of milliequivalents per dose, restricting access to the concentrated injection, and designating specific personnel to mix large- and small-volume parenteral solutions.
KCl shouldn't be on nursing floors
KCl was stored on patient floors in two Sonoma County (CA) hospitals, and as a result of its ready availability, two 80-year-old women died late last year. One was undergoing tests for pancreatic cancer at Community Hospital, and a nurse cleaning an IV line leading to the patient's heart used a vial of concentrated KCl instead of saline. The woman cried out, "This hurts," according to her daughter, just before she had a seizure and died. The other died at Santa Rosa Memorial Hospital when injected with the chemical. KCl has been removed from all patient areas except ICU and emergency departments at both facilities.
In a statement, Michael Cohen, president of the Institute for Safe Medication Practices in Warminster, PA, said, "These are preventable accidents. There is no reason for this drug not to be diluted in the pharmacy." The nurses face an investigation and possible disciplinary action by their state board. They will not be criminally charged, said Cohen.
The Medication Errors Reporting Program of the U.S. Pharmacopeial Convention in Rockville, MD, has received more than 23 voluntary reports of actual and potential errors involving KCl, including the following:
· Incident: A patient was to receive a series of epinephrine injections and saline, but received KCl instead of the saline. The nurse had mistaken the two similar-sized vials. Outcome: Cardiac arrest and brain damage.
· Incident: A nurse gave a 91-year-old woman KCl instead of the prescribed furosemide. Outcome: The patient's heart stopped within seconds.
· Incident: A 22-year veteran emergency department nurse injected a 56-year-old man with KCl instead of a diuretic. Both products were stored side by side in a cabinet on the nursing floor. Outcome: Death.
· Incident: A nurse used KCl instead of normal saline to flush a subclavian line in the ICU. The flip-top caps had been removed from the look-alike KCl and normal saline vials. Outcome: Patient went into ventricular fibrillation and was successfully resuscitated.
· Incident: Pharmacy personnel put a 250 mL bottle of undiluted KCl 20mEq/mL in a heparin premix storage bin. A practitioner who needed a heparin premix attached a pharmacy label to the KCl, and a patient received straight KCl IV. Outcome: Cardiac arrest.
Following the last incident, the facility recommended that pharmacy bulk containers of KCl be removed from the market. The glass bottles look too much like IV bottles.
KCl was mistaken for another drug in 20 of the 23 incidents; KCl was administered to the patient in 16 incidents.
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