Volume 5, No. 1 • Spring 1990

Potassium, Epi Removed to Prevent Accidental Misuse

Floyd Brauer, M.D.; Leslie Rendell-Baker, M.D.

To the Editor

Though we were aware of many unpublished deaths from the erroneous injo6on of concentrated potassium chloride, it was a similar tragic death in our own hospital when potassium chloride was injected instead of a diuretic that caused us to review our handling of potassium chloride and other concentrated solutions throughout our hospital.

We could not identify any circumstances on the ward or in the operating room where concentrated potassium chloride solution would be needed at a moment’s notice. As we have a 24-hour pharmacy intravenous preparation service, we withdrew the vials of concentrated potassium chloride solution from the operating rooms, ICU, and other patient care areas to be held in the hospital’s pharmacy. The pharmacy now pressure the diluted KC I solution ready for administration to the patient upon receipt of a prescription (order).

This arrangement prevents a repetition of these accidents, which we understand from the Medical Defence Union are a frequent cause of accidental hospital deaths in Britain.

We have also withdrawn epinephrine in the 1: 1000 concentration (1 mg in 1 ml) as this also is potentially lethal when injected without dilution. There have been many reports of accidents in which epinephrine was administered when ephedrine or Pitocin was intended. Epinephrine 1:10,000 solution is the concentration now stocked in our operating room.

We would urge hospital staffs to implement this policy wherever possible. In hospitals without a 24-hour pharmacy service, we would recommend that concentrated potassium chloride solution be kept under separate lock and key to prevent accidental confusion between KC I and NaCl vials in the hospital’s drug cupboards (especially in the O.R. and anesthesia work area).

It is hoped that the distinctive black flip-off type caps with black metal closures for vials and the black hands on ampoules, evolved by ASTM Subcommittee D I 0. 3 4 for these potentially lethal concentrated solutions, will help users identify them when this new packaging is adopted late in 1989.

Floyd Brauer, M.D.

Leslie Rendell-Baker, M.D. School of Medicine

Loma Linda (CA) University