["Concentrated KCL-free" hospital: stopping the use of potassium chloride concentrated ampoules in clinical departments and units--steps in implementing a new policy for increasing safety of drug therapy].
BACKGROUND
About one third of deaths of hospitalized patients associated with adverse drug reactions are due to hyperkalemia caused by administration of solutions that contain too high a concentration of potassium. Frequently, the reasons for these phenomena are mistakes that occur when the potassium obtained from the concentrated ampoule is diluted in the solution by department nurses. In the literature it is recommended to refrain from preparing such solutions in the departments, and to use premixed solutions which contain a known concentration of the potassium. The aim of the project was to achieve this goal in all clinical departments and units except general, pediatric, and neonatal intensive care units.


METHODS
The project took place during the years 2004-2006. Included were all 26 clinical departments and units in which solutions containing potassium chloride had been used, except general, pediatric, and neonatal intensive care units. The project was carried out with the full cooperation of the medical and nursing directors in each site and included the following steps: 1. Removing all ampoules of concentrated potassium chloride from the clinical sites. 2. Increasing the availability of factory prepared potassium chloride containing premixed solutions and standardizing their use. 3. Preparing potassium chloride containing solutions, that are not available premixed, only in the pharmacy. 4. Increasing the use of oral potassium chloride when possible.


RESULTS
As of January 2007: 1. In 26 (100%) of the clinical departments and units involved, no ampoules of concentrated potassium chloride are present as compared to only 2 (8%) departments that were free of the concentrate at the beginning of the project. 2. In these departments, nurses do not dilute potassium chloride. 3. The number of solutions containing potassium chloride available in the hospital has decreased from 20 to 10, all premixed. 4. No problems associated with potassium were observed in patients.


CONCLUSIONS
By implementing the recommendations in the literature regarding the use of potassium chloride solutions, the possible hazards of hyperkalemia associated with intravenous use were eliminated, thus taking a proactive approach to medication safety at HaEmek Medical Center.
Miron
Dan
D
The Quality Improvement Unit, HaEmek Medical Center, Afula, Israel. miron_da@clalit.org.il
Tiosano
Tuvia
T
Blondheim
Orna
O
Sorozkin
Anat
A
Moalem
Mazal
M
Goldstein
Lee
L
Moalem
Carolyn
C
D004356:Drug Storage; D017052:Hospital Mortality; D006801:Humans; D007557:Israel; D010607:Pharmacy Service, Hospital / Q000592:standards*; D011189:Potassium Chloride / Q000008:administration & dosage / Q000009:adverse effects*; D017751:Safety Management
D011189:Potassium Chloride