Reducing the risk of harm from intravenous potassium: a multi-factorial approach in the haematology setting

Barras, Michael, Moore, Diana, Pocock, Daniel, Sweedman, Myles, Wilkinson, Cathy, Taylor, Kerry and Morton, James (2013) Reducing the risk of harm from intravenous potassium: a multi-factorial approach in the haematology setting. Journal of Oncology Pharmacy Practice, OnlineFirst 1-10. doi:10.1177/1078155213504443

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Author Barras, Michael
Moore, Diana
Pocock, Daniel
Sweedman, Myles
Wilkinson, Cathy
Taylor, Kerry
Morton, James
Title Reducing the risk of harm from intravenous potassium: a multi-factorial approach in the haematology setting
Journal name Journal of Oncology Pharmacy Practice   Check publisher's open access policy
ISSN 1078-1552
Publication date 2013-09-20
Sub-type Article (original research)
DOI 10.1177/1078155213504443
Open Access Status
Volume OnlineFirst
Start page 1
End page 10
Total pages 10
Place of publication London, United Kingdom
Publisher Sage Publications
Collection year 2014
Language eng
Formatted abstract
Aims 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.
Keyword Potassium
Q-Index Code C1
Q-Index Status Provisional Code
Institutional Status Non-UQ

Document type: Journal Article
Sub-type: Article (original research)
Collections: Non HERDC
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Created: Thu, 24 Apr 2014, 12:30:54 EST by Dominique Rossouw on behalf of School of Medicine