Transcript Concentrated KCL - Health Quality & Safety Commission

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