Using Healthcare Failure Mode and Effect Analysis tool to review the process of ordering and administrating potassium chloride and potassium phosphate.
During the spring of 2004, in the Calgary Health Region (CHR) two critical incidents occurred involving patients receiving continuous renal replacement therapy (CRRT) in the intensive care unit (ICU). The outcome of these events resulted in the sudden death of both patients. The Department of Critical Care Medicine's Patient Safety and Adverse Events Team (PSAT), utilized the Healthcare Failure Mode and Effect Analysis (HFMEA) tool to review the process and conditions surrounding the ordering and administration of potassium chloride (KCI) and potassium phosphate (KPO4) in our ICUs. The HFMEA tool and the multidisciplinary team structure provided a solid framework for systematic analysis and prioritization of areas for improvement regarding the use of intravenous, high-concentration KCL and KPO4 in the ICU.
Esmail
Rosmin
R
Calgary Health Region, Calgary, Alberta, Canada. rosmin.esmail@calgaryhealthregion.ca
Cummings
Cheryl
C
Dersch
Deonne
D
Duchscherer
Greg
G
Glowa
Judy
J
Liggett
Gail
G
Hulme
Terrance
T
D000369:Aged, 80 and over; D000416:Alberta; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D008485:Medical Audit / Q000379:methods*; D019300:Medical Errors; D008510:Medication Systems, Hospital; D010710:Phosphates / Q000008:administration & dosage* / Q000627:therapeutic use; D011189:Potassium Chloride / Q000008:administration & dosage* / Q000627:therapeutic use; D017680:Potassium Compounds / Q000008:administration & dosage* / Q000627:therapeutic use; D051437:Renal Insufficiency; D017751:Safety Management
D010710:Phosphates; D017680:Potassium Compounds; D011189:Potassium Chloride; C013216:potassium phosphate