Improving the safety of high-concentration potassium chloride injection

ObjectivesSerious adverse effects, including arrhythmia and cardiac arrest, result from rapid intravenous high concentration of potassium chloride (KCl). We aimed to eliminate prescription of undiluted KCl and encourage dilution of KCl to 400 mEq/L and 40 mEq/L in the intensive care units (ICUs) and...

Full description

Saved in:
Bibliographic Details
Published in:BMJ open quality 2019-06, Vol.8 (2), p.e000666-e000666
Main Authors: Nakatani, Kaoru, Nakagami-Yamaguchi, Etsuko, Shinoda, Yoshikatsu, Tomita, Shuhei, Nakatani, Tatsuya
Format: Article
Language:English
Subjects:
adverse effect
Best practice
Chloride
Critical care
Drug administration
Drug dosages
Drug therapy
Health facilities
Injections
Intensive care
Intervention
Original
Original article
Patient safety
Pediatrics
Pharmacists
pharmacy
Physicians
potassium chloride administration
Prescriptions
Quality of care
safety management
Side effects
Citations: Items that this one cites
Items that cite this one
Online Access:Get full text
Tags: Add Tag
No Tags, Be the first to tag this record!
Description
Summary:ObjectivesSerious adverse effects, including arrhythmia and cardiac arrest, result from rapid intravenous high concentration of potassium chloride (KCl). We aimed to eliminate prescription of undiluted KCl and encourage dilution of KCl to 400 mEq/L and 40 mEq/L in the intensive care units (ICUs) and general and outpatient departments, respectively.MethodsBefore the first intervention, we collected data regarding high-concentration KCl and interviewed representatives of physicians prescribing high-concentration KCl. Based on the guidelines in other countries on safely used concentrations of KCl (400 mEq/L), we negotiated with physicians to dilute KCl below 400 mEq/L. In the first intervention, we made rules based on surveys above. In the second intervention, we revised the rules based on opinions from physicians and pharmacists and investigated the change in the number of prescriptions of KCl concentration in each department. Continuing efforts with the safety manager ensured compliance of the rules by physicians and nurses in all departments.ResultsAfter the first and second interventions, prescriptions for undiluted KCl in ICUs and general wards were eliminated (median=0). Prescriptions for
ISSN:2399-6641
2399-6641
DOI:10.1136/bmjoq-2019-000666