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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


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