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Publication Type: Patient Safety Alert
Single or Multiple Incident: Multiple
Date: 9/29/2021 12:00:00 AM
Country: South Korea
This alert describes two fatal medication incidents where concentrated (undiluted) potassium chloride (KCl) was injected instead of adding the KCl to an infusion solution or using a pre-mixed KCl solution. When administered directly, or as a bolus, KCl can cause serum electrolyte and EKG disturbances, arrythmias, cardiac arrest, and death. The alert provides recommendations for preventing incidents with concentrated KCl as well as guidelines for the safe use of undiluted KCl.

Additional Details

Medication/Gas/Fluid:
concentrated KCl for Injection premixed KCli nfusion
Medication/IV List:
potassium chloride for injection concentrate

Environment / Equipment
  1. The department of pharmacy and other permitted departments shall store the undiluted KCl in an area that is separated from the space where other medications are found.
Rules / Policies / Procedures
  1. Limit the use of undiluted potassium chloride (KCl) to the department of pharmacy and other permitted departments* (storage and use of KCl is prohibited in unpermitted departments).
  2. Prepare premixed KCL solutions in the department of pharmacy.
  3. Prescribe premixed KCl solutions (prohibit the prescription of the undiluted solution except for permitted departments).
  4. If the premixed solution is unavailable but the undiluted KCl is prescribed, use after completing preparation at the staff work area rather than the patient area if possible.
  5. Two healthcare providers shall accurately double check the dosage, directions, injection speed, and other factors right before an injection.
  6. Immediately before administering the finished product (pre-mix) or prepared solution containing KCl Check the correct product, mixing dosage, labeling, etc. according to the prescription.
  7. Patients and guardians shall not adjust the injection speed of the infusion solution, and any signs of erythema, pain, or others on the injection site must be notified to the healthcare provider immediately.
  8. It is highly recommended to use premixed Potassium Chloride (KCl) solution if possible. In unavoidable conditions, the undiluted Potassium Chloride (KCl) must be mixed with infusion solution for injection.
Training
  1. Standardization of the KCl content, standards, and unit: · Provide guidance and education regarding the types and contents of premixed KCl solution prepared in the department of pharmacy by using consistent units of measure.
  2. Perform training programs about safe KCl injection to all the relevant employees for the storage, prescription, preparation, and injection of premixed KCl solutions.

Fatal risk to patients from an intravenous injection of the undiluted Potassium Chloride (KCl)