Global Targeted Medication Safety Best Practice 3

Remove potassium concentrate injection from all inpatient drug storage on nursing units

Rationale:

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 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 intravenous (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 still occur to this day - around the world.

As a consequence, many organizations in countries like Australia, Canada, the United Kingdom, Northern Ireland, USA, Spain, New Zealand and Denmark have added concentrated potassium injections to their list of high-alert medications (2,4).

Goal:

The goal of this best practice is to prevent fatalities involving inadvertent injection of concentrated potassium in patient care areas (most often potassium chloride, potassium acetate and potassium phosphate injections).

Risk reduction strategies and key improvements:

A high leverage key safeguard is the removal of concentrated potassium products from all patient care areas. This becomes an even more effective intention as unit dose drug distribution systems are established as a standard of practice in inpatient settings, and when the pharmacy provides IV admixture services (5). This potent constraint has been supported by the WHO, The Joint Commission, The Joint Commission International, ISMP, ISMP Canada, United Kingdom, Australia, ISMP-España and others (2,5-12). The successful implementation of this intervention has avoided fatal errors (13). However, this recommendation is not always followed 100%, risking human life as deaths from the direct injection of potassium concentrates still occur. In the US, the Joint Commission does not permit potassium concentrate storage (including chloride, phosphate and acetate) in patient care areas (6).

Providing premixed potassium solutions is an additional fail-safe high level strategy. Standardisation of solution concentrations, and policies and procedures that limit storage conditions (e.g., giving exemptions and allowing storage in certain areas such as critical care and pediatrics), provide only medium and low leverage risk reduction strategies.

Improving injectable potassium packaging safety:

In North America and in some other parts of the world, the pharmaceutical industry is providing commercially premixed potassium solutions in multiple concentrations and multiple base solutions. Along with pharmacy IV admixture services, this enables complete removal of potassium concentrates from nursing units. 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 occur until the pharmaceutical industry makes these solutions available everywhere, at minimal expense.

Improving medication safety practices to reduce the risk of inadvertent administration of concentrated potassium

The International Medication Safety Network strongly advocates elimination of potassium concentrate injection in patient care areas in favour of using premixed or pharmacy-prepared solutions.

  1. Remove potassium concentrate injections from all inpatient drug storage on nursing units.
  2. Purchase and use premixed potassium solutions (already diluted in typical strengths for potassium replacement intravenously) (2,3,8,11).
  3. Prepare potassium solutions in the pharmacy for distribution internally within each hospital.
  4. Segregate and label storage locations of concentrated potassium injection in pharmacy preparation areas (3,11).
  5. Wherever possible, standardize potassium solution concentrations to eliminate the need for preparing potassium solutions that are not premixed or pharmacy-prepared.
  6. In scenarios where premixed solutions are not commercially-available, or a pharmacist and pharmacy preparation area is not available to prepare these solutions, or in hospitals without 24 hour pharmacies, IMSN recommends that:
    • Potassium concentrate vials or ampules should not be stored in clinical areas 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).

References:

  1. 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/
  2. World Health Organization. Patient Safety Solutions- Control of Concentrated Electrolyte solutions. Vol.1, solution 5, May 2007. Download
  3. Grissinger M. Potassium chloride injection still poses threats to patients. P&T. 2011; 36 (5): 241-302.
  4. Health professionals and authorities. Risk Situation Drugs. November 2018. Access
  5. 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.
  6. The Joint Commission. Medication error prevention—potassium chloride. Sentinel Event Alert, Issue 1, 27 February 1998.
  7. 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
  8. 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
  9. Institute for Safe Medication Practices Canada. Concentrated Potassium chloride: a recurring danger. ISMP Canada Safety Bulletin. 2004; 4 (3): 1-2.
  10. Reeve J, Allinson YM. High-risk medication alert: intravenous potassium chloride. Australian Prescriber 2005; 28:14-16. DOI: 10.18773/austprescr.2005.010
  11. 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
  12. Ministerio de Sanidad y Consumo. Recomendaciones para el uso seguro del potasio Intravenoso. Madrid, Ministerio de Sanidad y Consumo (2019) Access
  13. 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.