This document discusses guidelines for safely managing potassium chloride (KCl) administration in hospitals. It notes that concentrated KCl has been identified as high-risk and has caused patient deaths from misadministration. The document recommends that hospitals: 1) Develop multidisciplinary teams and guidelines to restrict concentrated KCl from patient units and standardize KCl orders and concentrations. 2) Make only premixed KCl solutions available to nursing units and require double verification for accessing any concentrated KCl. 3) Involve pharmacy in preparing premixed KCl solutions, applying additional warning labels, and intervening on nonstandard orders. 4) KFSH-D in Dammam follows these safety practices by prohib

1. Potassium Chloride and Patient Safety Yasser Gebril Pharmacy Services Department. King Fahad Specialist Hospital-Dammam.

2. Table of Contents: Importance of Potassium Potassium Toxicity Epidemiology Causes of Hyperkalemia Diagnosis of Hyperkalemia The Need for Potassium Dosing Guidelines JCI Recommendation UK Guidelines KFSH-D Potassium Chloride Dosing Guidelines ISMP Recommendations Hospital Administration Physician and P&T Committee Nursing Units and Pharmacy

3. Importance of Potassium Potassium is the primary intracellular ion in the human body. The normal plasma potassium concentration range is 3.5 to 5 mEq/L. Potassium regulates many biochemical processes in the body, and is a key ion for electrical action potentials across cellular membranes. Potassium chloride is the preferred potassium supplement for the most common causes of hypokalemia. Hyperkalemia commonly results in patients with acute or chronic kidney disease. Pharmacotherapy Handbook, Seventh Edition

4. Potassium Toxicity HYPOKALEMIA: Hypokalemia is defined as Serum potassium less than 3.5 mEq/L. Pathophysiology Hypokalemia results from a total body potassium deficit or shifting of serum potassium into the intracellular compartment. Pharmacotherapy Handbook, Seventh Edition

5. Potassium Toxicity, Con… HYPERKALEMIA: Hyperkalemia is defined as a serum potassium concentration greater than 5.5 mEq/L. It can be further classified according to its severity: Mild (serum potassium 5.5 to 6 mEq/L). Moderate (6.1 to 6.9 mEq/L); and Severe hyperkalemia (>7 mEq/L). Pharmacotherapy Handbook, Seventh Edition

6. Epidemiology The incidence of hyperkalemia in hospitalized patients has been estimated to be 1.4% to 10%*. Most cases of hyperkalemia are the result of overcorrection of hypokalemia with potassium supplements. Severe hyperkalemia occurs more commonly in elderly patients with renal insufficiency who receive potassium supplementation. *Journal of Hospital Medicine Volume 6, Issue 3, pages 136–140, March 2011

7. Causes of Hyperkalemia Increased potassium intake Decreased potassium excretion Tubular unresponsiveness to aldosterone. Redistribution of potassium into the extracellular space.

8. Diagnosis of Hyperkalemia Clinical Presentation Of Hyperkalemia General Related to the effects of excessive potassium on neuromuscular, cardiac, and smooth muscle cell function. Symptoms Frequently asymptomatic; however, the patient may complain of heart palpitations or skipped heartbeats. Signs ECG changes Laboratory Tests Serum potassium concentration >5.5 mEq/L.

9. Why Do We Need To Have Guidelines? Concentrated potassium chloride has been identified as a high risk medication by organizations in Australia, Canada, and the United Kingdom In the United States, ten patient deaths from misadministration of concentrated KCl solution were reported to the Joint Commission in just the first two years of its sentinel event reporting program: 1996–1997 In Canada, 23 incidents involving KCl misadministration occurred between 1993 and 1996. Patient Safety Solutions, volume 1, solution 5, May 2007

10. Why Do We Need To Have Guidelines? The following incidents with potassium chloride have been reported to ISMP Canada: 10 mL potassium chloride (KCl) concentrate was administered direct IV when the intended action was to flush an intravenous line with 10 mL Normal Saline Result: patient Death. 10 mL KCl concentrate was used to reconstitute a drug for parenteral administration when the intended diluent was sterile water, Result: Near miss (error was noted before administration). ISMP Canada Safety Bulletin, Volume 2, Issue 5 May, 2002

11. Why Do We Need To Have Guidelines? 10 mL KCl concentrate was administered as a bolus injection by a healthcare professional who was unaware that KCl concentrate cannot be given as a bolus but diluted and given as an infusion. Result: patient Death. A one-liter IV solution was prepared with 400 mEq of KCl and although it was administered at a very low rate, the incident was felt to be a near miss because of the potential for accidental overdose.(error was noted during administration). IV solutions containing KCl were administered as a fluid replacement in a patient requiring several liters of fluid in a short time frame. Result: hyperkalemia, Death

12. JCI Recommendations International Patient Safety Goals (IPSGs) include: “Improve the Safety of High-Alert Medications” with the recommendations to: Policies and/or procedures are developed to address the identification, location, labeling, and storage of high-alert medications. Concentrated electrolytes are not present in patient care units unless clinically necessary, and actions are taken to prevent unintended administration in those areas where permitted by policy. Standardize and limit the number of drug concentrations available in the organization

13. United Kingdome The National Patient Safety Agency established by the National Health Service (NHS ) issued a Patient Safety Alert in July 2002 to all Chief Executives of National Health Service Trusts and Primary Care Trusts in Britain. It required actions in all centers of the (NHS) to reduce the potential for patient injury with the use of potassium chloride by October 31, 2002. In the Alert, one of the strategies suggested that: “Pharmacists should also remove potassium chloride concentrate from wards and clinical areas, use commercially prepared diluted potassium solution where possible, and store potassium chloride concentrate in a separate locked cupboard.”

14. ISMP KCl Safety Recommendations Hospital Administration Physicians and P&T Committee Nursing Units and Pharmacy ISMP Canada Potassium Chloride Safety Recommendations Summary 2005

15. 1- Hospital Administration Create a high-level multidisciplinary team with a mandate to: Reduce the error potential of potassium chloride (KCl). Define an implementation strategy (including timelines). Provide regular updates to the hospital board’s Quality & Risk Management Committee. Include discussion of KCl injury and preventive system safeguards during orientation programs for nurses, physicians, and pharmacists and locum staff

16. 2- Physicians and P&T. Committee Pharmacy and Therapeutics Committee to develop clear guidelines for the use of KCl, including: Use of oral, instead of IV KCl whenever clinically feasible. Standardization of prescribing practices to match available premixed KCl solutions. Maximum concentration of KCl allowable in an IV solution. Maximum hourly and daily limits of KCl that a patient may receive. Maximum infusion rate. Requirements for infusion rate and patient monitoring. Evaluation of need and/or feasibility of automatic substitution policy.

17. Physicians and P&T committee’ Cont. Identify that orders such as “KCl 40 mEq IV now” or “give KCl 20 mEq IV bolus” should be considered incomplete and unacceptable. Orders require instructions for dilution and infusion rate. If it is deemed necessary that concentrated KCl products be available in a critical care area, create policies to restrict and safeguard their use. Consider a locked cupboard and/or a double sign-out procedure for obtaining the concentrated product

18. 3- Nursing units Have each patient care unit, program, department, and clinic undertake a review by physicians, nurses and pharmacists with the following aims: Have standardized premixed KCl IV solutions available in adequate quantities. Store premixed KCl solutions separately from plain IV solutions. If concentrated KCl products must be available in a critical care area, follow P&T policies regarding access, e.g., locked cupboard and/or a double sign-out procedure for obtaining the product.

19. 4- Pharmacy Work with the appropriate department(s), e.g. Inventor& Supplies and Nursing, to arrange for storage and distribution of premixed KCl IV solutions. Consider purchasing only the 40 mEq /20 mL size concentrate (not 20 mEq/10 mL size) to minimize the chance of mix-up with other commonly used products such as 10 mL sterile water and 10 mL normal saline. Pharmacy should prepare any nonstandard solutions that are deemed absolutely necessary but are unavailable commercially in a premixed format. Minibag products containing KCl should be dispensed and controlled by the pharmacy only.

20. Pharmacy, continued Add auxiliary warning label to premixed minibags containing KCl, providing the recommended route of administration (e.g., “central line only”) and the recommended duration of infusion (e.g., “infuse over at least 1 hour”). Have pharmacists intervene when nonstandard orders for IV solutions with KCl are prescribed. Prescribing practices must take into consideration the premixed KCl IV solutions that are available. Choose a designated area for storing concentrated KCl products in the pharmacy to reduce the likelihood of substitution errors.

21. KFSH-D Potassium Dosing Guidelines

22. Potassium Management in KFSH-D No concentrated KCl in patient care areas. Only 20mL (2mEq/mL) KCl vials are used in KFSH-D pharmacy. All KCl used in KFSH-D is premixed (diluted) in the pharmacy before dispensing. All medications (not only high alert medications) dispensed from pharmacy have double signatures.

23. Think safethink twicedouble check

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