Remove potassium concentrate injection from drug storage areas on all inpatient nursing units/wards.
Potassium is an electrolyte replenisher required for the maintenance of several physiological processes in the body (1). Frequently used to treat hypokalemia and other electrolyte abnormalities, intravenous (IV) potassium is available in vials or ampules as a concentrate for dilution (1). Improper administration of concentrated electrolytes is dangerous (2). Tragic errors have occurred due to rapid IV administration of concentrated potassium solutions or wrong product selection (potassium concentrate mistaken for another drug) (3). Vials or ampules of potassium have also been accidentally used instead of sterile water or normal saline (0.9% sodium chloride) to dilute vials of powdered or lyophilized drugs. Outcomes have often been fatal in children and adults, and errors still occur worldwide to this day.
As a consequence, many organizations in countries such as Australia, Brasil, Canada, Denmark, New Zealand, Northern Ireland, Spain, United Kingdom, and United States have added concentrated potassium injections to their list of high-alert medications and have implemented risk-reduction strategies to prevent errors and mitigate patient harm ( 2-7).
The goal of this best practice is to prevent fatalities involving inadvertent injection of concentrated potassium on nursing units/wards (most often potassium chloride, potassium acetate and potassium phosphate injections).
Best Practice Description
IMSN strongly advocates for the elimination of potassium concentrate injection in nursing units/wards in favor of using premixed or pharmacy-prepared solutions containing potassium.
- a) Remove potassium concentrate injections from all inpatient drug storage on nursing a) units/wards (7).
- b) Purchase and use premixed potassium solutions (already diluted in typical strengths for IV potassium replacement) (2,3,5,6).
- c) Wherever possible, standardize potassium solution concentrations to eliminate the need for preparing potassium solutions that are not premixed or pharmacy-prepared.
- d) When necessary, prepare potassium solutions in the pharmacy for distribution internally within each hospital.
- e) In scenarios where premixed solutions are not commercially-available, when a pharmacist and pharmacy preparation area is not available to prepare these solutions, or when 24-hour pharmacy service is unavailable:
- Potassium concentrate vials or ampules should not be stored on nursing units/wards but instead be stored centrally, outside the pharmacy, in a locked cabinet.
- Potassium concentrate vials or ampules should be placed in a clear plastic bag with warning stickers and instructions for dilution.
- Only qualified and trained individuals (e.g., physician, nurse) should have access to these vials or ampules to prepare potassium solutions (3,7).
- f) Segregate and label storage locations of concentrated potassium injections in pharmacy preparation areas (3,6,7).
Removal of concentrated potassium injection products from all patient care areas is a high-leverage, key safeguard. This strategy becomes an even more effective intervention when unit dose drug distribution systems are established as a standard of practice in inpatient settings, and when the pharmacy provides IV admixture services (7). This potent constraint has been supported by the World Health Organization (WHO), Joint Commission International, United Kingdom, Australia, The Joint Commission, ISMP, ISMP Brasil, ISMP Canada, ISMP-España, and others (2,7-12). The successful implementation of this best practice has avoided fatal errors (13); however, ongoing access to concentrated potassium injection in nursing units/wards risks human lives and continues to result in fatalities from the direct injection of this product. In the United States, The Joint Commission does not permit potassium concentrate injection storage (including potassium chloride, potassium phosphate, and potassium acetate) in patient care areas (13).
Providing premixed potassium solutions in standard concentrations is an additional high-leverage risk-reduction strategy. However, limiting storage of the concentrated potassium injection outside of the pharmacy but allowing exemptions in certain areas such as critical care and pediatrics provides less protection from errors than removing the product from all nursing units/wards.
Improving Availability of Premixed Potassium Solutions:
In North America and in some other parts of the world, the pharmaceutical industry provides commercially premixed potassium solutions in multiple concentrations and base solutions. Along with pharmacy IV admixture services, this enables complete removal of potassium concentrates from nursing units/wards. However, these premixed solutions are not available in many countries globally, making it difficult to comply with a ready-to-use, ready-to-administer approach. Unnecessary deaths from direct injection of concentrated potassium will continue to occur until the pharmaceutical industry makes these premixed solutions available everywhere, at minimal expense. IMSN urges the global pharmaceutical industry to make premixed potassium solutions available everywhere as soon as possible.
- Potassium chloride, Potassium acetate, Potassium phosphate. Mechanism of action. (2018). In Micromedex. Greenwood Village, CO: Truven Health Analytics. Retrieved December 15, 2018, from http://www.micromedexsolutions.com/
- World Health Organization. Patient Safety Solutions- Control of Concentrated Electrolyte solutions. Vol.1, solution 5, May 2007. Download
- Grissinger M. Potassium chloride injection still poses threats to patients. P&T. 2011; 36 (5): 241-302.
- Danish Patient Safety Authority. Health professionals and authorities. Risk Situation Drugs. November 2018. Access
- Australian Council for Safety and Quality in Health Care Intravenous POTASSIUM CHLORIDE can be fatal if given inappropriately. Safety and Quality Council Medication Alert! Alert 1. October 2003. Download
- New Zealand Medicines and medical devices safety authority. Medication Alert- Concentration potassium chloride injection can be fatal if incorrectly administered! Quality and safe use of medicines. July 2008. Download
- Cohen MR, Smetzer JL, Tuohy NR and Kilo CM. High-Alert Medications: safeguarding against errors. In Medication Errors. 2nd ed. Washington (DC): American Pharmaceutical Association. 2007; 257,323,399-401.
- National Health Services (NHS) National Patients Safety Agency. Patient Safety Alert 01. Risks to patients from errors occurring during intravenous administration of potassium solutions. 23 July 2002. NPSA London. Download
- Institute for Safe Medication Practices Canada. Concentrated Potassium chloride: a recurring danger. ISMP Canada Safety Bulletin. 2004; 4 (3): 1-2.
- Reeve J, Allinson YM. High-risk medication alert: intravenous potassium chloride. Australian Prescriber 2005; 28:14-16. DOI: 10.18773/austprescr.2005.010
- Ministerio de Sanidad y Consumo. Recomendaciones para el uso seguro del potasio Intravenoso. Madrid, Ministerio de Sanidad y Consumo (2019) Access
- Lankshear AJ, Sheldon TA, Lowson KV, Watt IS, Wright J. Evaluation of the implementation of the alert issued by the UK National Patient Safety Agency on the storage and handling of potassium chloride concentrate solution. Qual. Saf. Health Care 2005;14:196-201.
- The Joint Commission. Medication error prevention—potassium chloride. Sentinel Event Alert 27 February 1998; (1): 1-2.