Risks to Patients from errors in the use of potassium chloride occurring during the reconstitution of drugs for injection

Abstract

 Medication errors are preventable events that lead to inappropriate medicine use, thus, causing harm to patients' health. Parenteral potassium chloride has been one of the drugs most frequently associated with medication errors that proved fatal to patients, being classified as a high-risk medication. The majority of these errors involve the accidental substitution of the suitable diluent for a potassium chloride solution, when reconstitution of injectable drugs. The aim of this study is to assess the occurrence of possible errors in the reconstitution of drugs in hospitals by determining potassium, and then to suggest safety measures to prevent such errors. The study was carried out with residues of ten reconstituted samples sent by hospitals due to adverse effects in the patients who have received these medications, for the purpose of the identification of drugs and dosage of potassium, due to a suspicion of potassium chloride being mistakenly used as their diluent. The results were that a total of 4 samples have shown potassium values that were compatible with a solution of potassium chloride 19,1%, confirming that there has been error the use of potassium chloride as a diluent, which may have resulted in the deaths listed in the medical reports; 4 samples have shown potassium values that were considered normal; and 2 samples have shown inconclusive results. The safety measures proposed recommend that the type and volume of the diluent to be used in the drug reconstitution should be specified on the label; that there be a simultaneous dispensing of medications and diluent, previously reconstituted or fractionated (single dose); and that the nursing team supervise the process of drug reconstitution and/or dilution and the maintenaince of the potassium chloride solution in a safe and restricted place, thus reducing the number of occurrences.