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