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1. |
Key Words
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Potassium Chloride, Storage, Prescribing
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| 2. |
Objectives
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This paper outlines the GHP position on the storage and prescribing of strong potassium chloride injection and seeks to offer guidance to pharmacists on their responsibilities in this area.
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| 3. |
Introduction
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Several critical incidents that have occurred with strong potassium chloride injection, demonstrate the need for a clear management policy for this high risk agent. Pharmacists must ensure that they play a key role in ensuring that this agent is stored and utilised appropriately. While this policy relates to strong potassium chloride injection, it's principles may also apply to other strong potassium injections such as Potassium Acid Phosphate.
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| 4. |
Statement
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| 4.1. |
The Guild of Healthcare Pharmacists believes that due to the level of risk associated with potassium chloride injection, ampoules of strong potassium chloride should not be kept as a stock item in wards and departments where reconstitution and/or administration of medicines takes place. In clinical areas where high concentrations and doses of potassium chloride are routinely utilised e.g. Intensive Care Unit, a risk assessment must be undertaken to ascertain whether it is appropriate to keep this agent as a stock item rather than using premixed potassium solutions.
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| 4.2. |
In clinical areas where it remains as stock it should be stored separately from sodium chloride and other commonly used injections and the storage area clearly marked with a warning. The controlled drug cupboard should be the preferred storage area.
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| 4.3. |
Medical staff should prescribe from the range of pre-mixed potassium chloride containing intravenous fluids available. Potassium chloride ampoules should not be used to prepare intravenous fluids where pre mixed bags are available.
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| 4.4. |
Prescriptions for potassium chloride infusions must state clearly the dose and infusion fluid required.
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| 4.5. |
Nursing and junior medical staff should be made aware of the potassium chloride risks through the new starter integration and IV training courses. This should be supported by the provision of information by pharmacists.
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| 5. |
References
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Cousins DH, Upton DR. Medication error report series. Pharmacy in Practice 2000;10:187
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JCAHO Sentinel Event Alert, Issue 1, February 27,1998
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"Act now to prevent KCL deaths". Medication error report series.
Cousins DH, Upton DR. Pharmacy in Practice 1996;6;307,310
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ISMP Medication Safety Alert, August 28, 1996 Issue
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"Lethal Ampoules are still being issued". Medication error report series.
Cousins DH, Upton DR. Pharmacy in Practice 1995;5;130-2
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"Stop these parenteral blunders". Medication error report series.
Cousins DH, Upton DR. Pharmacy in Practice 1994;4;387-390
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| 6. |
Cross Reference to Other Statements
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| 6.1 |
GHP Policy Statement Number: 001/1 on medication errors
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