title: Intravenous potassium predicament.
abstract: In 1991, United States Pharmacopeia (USP) required modification of the nomenclature and packaging standards for potassium chloride injection following reports of deaths that occurred due to inadvertent medication administration errors. The following article taken from USP Quality Review provides a brief history of the revised standards and a current Medication Errors Reporting (MER) Program database analysis of potassium chloride misadministrations. Also included is an errors table that compiles and abstracts all actual and potential errors of potassium chloride for injection concentrate that were received through August 1996. Because errors continue to be reported, USP Practitioners' Reporting Network would appreciate continual communication about the potential for error when administering potassium chloride for injection concentrate. Reprinting of this review is encouraged. A camera-ready format also is available by contacting USP Practitioners' Reporting Network at 800-487-7776.
mesh_terms: D006801:Humans; D008508:Medication Errors; D011188:Potassium / Q000627:therapeutic use*; D019064:Product Packaging; D009626:Terminology as Topic
chemical_list: D011188:Potassium