Date post: | 03-Jan-2016 |
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Concentrated Potassium Chloride (KCL)
Sentinel event
• Concentrated KCL – multiple cases in international literature of inadvertent injection of concentrated KCL (often fatal).
• Recent NZ case involving nurse who thought that she was injecting heparinised saline, but was actually injecting concentrated KCL. 9 year-old boy arrested (was resuscitated).
Root causes of KCL incidents
1. Look alike ampoules – KCL ampoules look like other low risk ampoules
2. Storage of KCL
3. Human factors – distraction, poorly organised environment, lighting, high workload
Concentrated KCL: the problem
"The way to prevent tragic deaths from accidental intravenous injection of concentrated KCl is excruciatingly simple -- organizations must take it off the floor stock of all units. It is one of the best examples I know of a 'forcing function' -- a procedure that makes a certain type of error impossible."
Lucian L. Leape, M.D. Harvard School of Public Health
KCL Alert
Concentrated KCL: the solution
1. Remove KCL from wards, replace with pre-mixed bags
2. Store KCL in red click/clack boxes away from other ampoules
3. Store KCL in Pyxis machines