Asking These Questions Can Save a Life!

Administration of concentrated potassium chloride (KCl) by IV push is deadly — it will stop the heart. In June, ISMP reported the first KCl IV push accidental fatality in 14 years. 

 

This event occurred during a code in the intensive care unit and involved a series of miscommunications and incorrect assumptions. The hospital stored the concentrated KCl vials only in the pharmacy department, consistent with The Joint Commission (TJC) standards since 2003. Upon pharmacist request, a vial was delivered to the patient's room, where it was subsequently administered IV push, resulting in the patient's death.

 

Ask yourself - could this happen at your organization? If you stock vials of KCl or have access to it, the answer is YES, and it's time to take action! Read the case available on ISMP's website. Take time to discuss it with your staff and leadership, and plug the "holes" now to avoid a similar event.

 

Do you have a list of drugs that should never leave the pharmacy?  If not, see the starter list below. ALL pharmacy staff should be aware of it, and signage should be posted near storage of all the "never drugs" and near your tube station. Quiz often.

 

Does everyone in your department feel comfortable asking questions about potential safety concerns? It might be time to take the pulse of your safety culture. Empower everyone - at all levels - to ask for clarification. This might include a pharmacy technician who retrieves the vial from the storage area, the person who is asked to deliver the vial to the patient care unit, the pharmacist who authorizes the vial to leave the pharmacy and the pharmacist who requested the vial based on the doctor's incomplete request. Even one question might be enough to prevent tragedy.

  

Medications that should not be stored or dispensed outside the pharmacy department are listed below. (If your organization requires storage in a specific patient care area due to a unique situation, requirements for special handling, labeling, dispensing and accountability should be defined in policy and easily accessible to all users.)

- Concentrated electrolytes (e.g. KCl, NaCl 3% or greater)

- Concentrated insulin U-500

- Concentrated oral opioid solutions

- Sterile water in bags

- Concentrated epinephrine multi-dose vials

- Neuromuscular blocking agents