Reducing the risk of harm from intravenous potassium: a multi-factorial approach in the haematology setting.
OBJECTIVE
To describe the implementation of safety systems for the use of intravenous potassium chloride in haematology patients.


METHODS
We assessed the use of intravenous potassium in a haematology ward at a tertiary hospital. Initially, we prospectively analysed the prescribing and administration of intravenous potassium to all patients over a two-week period. To complement this data, we retrospectively analysed all clinical incidents involving intravenous potassium and the dispensing patterns of potassium ampoules for the past 12 months. Drawing on evidence and recommendations from international safety literature, gaps in the safe use of potassium were identified, and a multi-factorial approach to system change was implemented.


RESULTS
A total of 18 patients were analysed with 90 intravenous bags of potassium prepared on the ward using 624 ampoules. We identified multiple opportunities for error and a lack of standardisation of therapy. The following safety systems were introduced: (i) a new prescribing and monitoring form that included dose calculation, prescriber support and pre-printed orders; (ii) removal of potassium ampoules and introduction of premixed bags; (iii) independent double checking by nursing staff at point of administration; (iv) dedicated labelling of intravenous lines; (v) extensive clinician training supported by guidelines; and (vi) introduction of 'smart pump' infusion software. The number of incidents significantly reduced from 23 to 9 (p < 0.001), and the number of ampoules dispensed reduced from 10,100 to 0.


CONCLUSIONS
A multi-factorial approach to the safe prescribing, dispensing and administration of intravenous potassium has reduced the potential for patient harm in the haematology setting.
Medication Safety and Quality Unit, Mater Health Services; Pharmacy Department, Royal Brisbane and Women's Hospital, Herston, QLD, Australia michael.barras@bigpond.com.
Michael
M
Barras
Mater Private Hospital, South Brisbane, Australia.
Diana
D
Moore
Mater Health Services, South Brisbane, Australia.
Daniel
D
Pocock
Mater Private Hospital, South Brisbane, Australia.
Myles
M
Sweedman
Mater Health Services, South Brisbane, Australia.
Cathy
C
Wilkinson
Mater Medical Centre, Centre for Haematology, South Brisbane, Australia.
Kerry
K
Taylor
Mater Medical Centre for Haematology, South Brisbane, Australia.
James
J
Morton
D002626:Chemistry, Pharmaceutical; D016503:Drug Delivery Systems / Q000295:instrumentation; D054796:Drug Dosage Calculations; D004349:Drug Packaging; D004867:Equipment Design; D006405:Hematology / Q000379:methods* / Q000592:standards; D006801:Humans; D007260:Infusion Pumps; D007262:Infusions, Intravenous; D008508:Medication Errors / Q000517:prevention & control*; D061214:Patient Safety; D010607:Pharmacy Service, Hospital; D011189:Potassium Chloride / Q000008:administration & dosage* / Q000009:adverse effects*; D015397:Program Evaluation; D011446:Prospective Studies; D058996:Quality Improvement; D019984:Quality Indicators, Health Care; D011793:Queensland; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012984:Software; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome
D011189:Potassium Chloride
Potassium; haematology; safety; standardisation