Intravenous potassium chloride

Editor, – Recommendations from the Safety and Quality Council regarding the 'High-risk medication alert: intravenous potassium chloride' (Aust Prescr 2005;28:14-16)warrant further comment.

Many elderly and frail patients requiring parenteral potassium supplementation are readily at risk of volume overload if administered potassium salts in dilute infusions, as illustrated in the article. High dependency and intensive monitoring areas are now being approached to admit and supervise patients merely for the intravenous administration of concentrated potassium salt, or at worst to manage the consequences of volume overload in those patients given the premixed but dilute solutions on general wards.

Unfortunately staffed beds in such acute areas are usually inconsistently available. The patient is then denied timely potassium replacement therapy or at worst suffers the consequences of delay or volume overload.

Could there not be a more practical approach to developing a safety checking protocol than the recommendations promulgated? It is difficult to believe that any clinically active medical or nursing staff were participants in the recommendations thrust upon and slavishly adopted as a mandate by hospitals nationwide.

P.D. Cameron
Senior Staff Specialist, Department of Intensive Care
Sir Charles Gairdner Hospital
Nedlands, WA

Yvonne Allinson, one of the authors of the article, comments:

Before the release of the first Safety and Quality Council high-risk medication alert, there were examples of innovative and successful risk minimisation projects for intravenous potassium initiated by hospital staff in Australia. The alert sought to raise awareness more broadly and make high level suggestions to assist other facilities, including those without dedicated risk management teams.

The alert asked all facilities to evaluate their current controls against a range of recommended actions. The actions suggested were compiled from the international literature and case studies, Australian adverse incident case studies, positive change management strategies from many hospitals, and consultation with key organisations.¹

The alert covered a range of topics where there may be confusion when treating hypokalaemia. These included route of administration, intravenous doses in millimoles only, maximum concentration/rate and the availability of a variety of clinically appropriate premixed dilutions. Importantly it suggested roles for all hospital clinical staff as well as chief executives and key committees.

The alert has stimulated further innovation to make potassium use safer. Facilities need to do their own risk assessment and to develop protocols for safe preparation and use of intravenous potassium. Hospital and facility-based teams are encouraged to draw on local expertise at all levels so that this can be done to safely manage the different clinical risks of individual patients. The alert does not preclude this, rather it hopes to catalyse and encourage such action with follow-up audit, review, evaluation and improvement.

Dr Ross Wilson, Chair, National Medication Safety Taskforce, comments:

Dr Cameron highlights a very important issue. That issue is hospitals creating new problems or risks for patients by the way they respond to high level policy recommendations.

The National Medication Safety Taskforce was established in October 2001 to advise the Australian Council for Safety and Quality in Health Care and hence Health Ministers from all jurisdictions, on the reduction of patient harm from the use of medications. It was hoped that the provision on the Council website1of case studies from four hospitals from different states would assist with implementation. In addition, the Taskforce hosted a meeting late in 2004 on the practical aspects of implementation of this policy with many key stakeholders, including clinicians. The variation in practice and even knowledge about available potassium products was marked. The other key observation of this group was that reducing the need for intravenous replacement of concentrated potassium should be the subject of major efforts by clinical groups. Recommendations from this meeting are currently being considered, and at the very least could set the scene for better sharing of implementation lessons, as well as agreement to assess the extent of effective reduction of patient risk by local changes in the availability of ampoules of concentrated potassium.

A US survey by the Institute for Safe Medication Practice² found that 96% of clinicians and pharmacists considered that concentrated potassium ampoules were a high-alert medication, with 90% of their organisations having put in place special precautions to reduce the likelihood of error.

If the changes that are made in response to the Australian alert are themselves problematic, then the alert will not have entirely served its purpose. Fortunately, with the passage of time and the sharing of experience this is becoming very much less of an issue. Addressing the clinical management of potassium replacement in hospitals will go a long way to reducing the 'apparent' need for ampoules of concentrated potassium, but will require significant clinical leadership at professional and jurisdictional level.

Editor, – We read with interest the report 'High-risk medication alert: intravenous potassium chloride' (Aust Prescr 2005;28:14-16)and felt it timely to describe our local experience in a tertiary paediatric hospital.

A small multidisciplinary team (medical, pharmacy and nursing) implemented changes on behalf of the Drug Utilisation Review Committee over a 10-month period, in accordance with Australian Council for Safety and Quality in Health Care recommendations.³

An initial intervention took place in March 2004, including the following: removal of excess supplies of potassium-containing ampoules from ward areas, with limited supplies placed in red-labelled boxes in locked medication cupboards. All potassium-containing ampoules were then ordered through the dangerous drugs register, rather than as ward stock. Three preparations of pre-mixed fluids were introduced, each containing 10 mmol KCl per 500 mL (all fluids were 500 mL bags). These changes were audited two and seven months after the intervention.

Adherence to new storage practices for potassium-containing ampoules was noted at the time of the audits in all wards of the hospital. The introduction of pre-mixed intravenous solutions led to a stepwise, substantial reduction in the need for ampoules of concentrated potassium on the wards. As a result, it was possible to remove the ampoules from the majority of general wards of the hospital, without compromising patient care.

The applicability of our project to other institutions presents several challenges. The choice of intravenous solutions varies considerably between the states of Australia, and there is currently no consensus regarding 'ideal' pre-mixed solutions for paediatric patients.

Yashwant Sinha
Fellow in Clinical Pharmacology

Carolyn Dubury
Senior Pharmacist

Phillip Grant
Nursing Unit Manager, Oncology

Drug Utilisation Review Committee
Sydney Children's Hospital
Randwick, NSW

Acknowledgment: Dr Andrew Numa for review of the manuscript.