Fatal Potassium Error

Floyd S. Brauer, M.D.

To the Editor

A tragic death from erroneous intravenous injection of concentrated potassium chloride solution instead of the intended diuretic precipitated a review of our handling of potassium chloride and other concentrated solutions throughout our hospital.

We could not identify any circumstances in which concentrated potassium chloride solution would be needed at a moment’s notice. As we have 24-hour pharmacy intravenous preparation service, we withdrew the vials of concentrated potassium chloride solution from the OR, ICU, and other patient care areas to be held in the hospital’s pharmacy. The pharmacy now prepares the diluted KCI solution ready for administration to the patient on receipt of a prescription.

This arrangement prevents a repetition of the previous accident, which we understand from the British Medical Defence Union is a frequent cause of accidental hospital deaths in Britain.

We have also withdrawn epinephrine in the 1: I 000 concentration (I mg in I ml) as this also is potentially lethal. There have been many reports of accidents when epinephrine was administered when ephedrine or Pitocin was intended. Epinephrine 1: 1 0,000 solution is the concentration now stocked in our operating rooms.

We would urge our colleagues to implement this policy wherever possible. In hospitals without 24-hour pharmacy service, we would recommend that concentrated potassium chloride solution be kept under separate lock and key to prevent accidental confusion between KCI and NaCl vials in the hospital’s drug cupboards.

Floyd S. Brauer, M.D., Professor and Chairman and Leslie Rendell-Baker, M.D. Professor, Department of Anesthesiology Loma Linda University (CA).