Authors (including presenting author) :
Medication Safety Subcommittee members(1), Lee AWK(1)(2)
Affiliation :
(1)Grantham Hospital Medication Safety Subcommittee, (2) Pharmacy Department, Grantham Hospital
Introduction :
The devastating outcomes associated with errors in the administration of concentrated potassium chloride injection (cKCl) are recognized worldwide. Incidents arise from similar packaging between cKCl and normal saline leading to picking errors. Others have been attributable to preparation or administration mistakes. Measures were developed by the Hospital Authority to minimize cKCl related incidents such as limiting ward stock to critical units and introducing ready to use pre-mixed potassium chloride (KCl) preparations. Despite the implementation of all measures, the consumption of pre-mixed KCl in Grantham Hospital (GH) was found to remain low while cKCl use was escalating. Medication Safety Subcommittee (MSS), a multidisciplinary team of doctors, pharmacists and nurses reviewed the situation and regarded lack of awareness and difficulty in recalling available pre-mixed KCl preparations as the main contributing factor.
Objectives :
To promote the prescribing of commercial pre-mixed potassium chloride preparations.
Methodology :
1) Since IPMOE is yet to be implemented in GH, a Medication Administration Record (MAR) solely for the prescribing of intravenous potassium chloride with listing of all available pre-mixed KCl preparations on the MAR was devised. 2) A review of pre-mixed KCl preparations in GH was conducted by Hospital Drugs and Therapeutics Committee to best cater for current prescribing needs. 3) To reinforce local adaption of HA recommendations and provide guidance for the new MAR, GH Guideline on the Safe Management of KCl IV Preparations was developed. 4) A two week trial / grace period was employed to identify any prescribing or logistical issues before full roll out on 30th April 2018.
Result & Outcome :
To reduce the usage of concentrated potassium chloride injection. Consumption of cKCl has reduced by 46% while pre-mixed KCl preparations have increased by 22% between May-October 2017 and 2018. By proportion, consumption of cKCl vs pre-mixed has shifted from approximately 50:50 to 25:75. A team approach in tackling the problem on hand, coupled with clear promulgation through MSS members to own specialty, the introduction of the new MAR was seamless and well received. With concerted effort from all stakeholders the objective and goal, to shift prescribing practice and reduce cKCl use were reached, enhancing safety at drug administration.
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