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Concentrated Potassium Chloride (KCL)

Concentrated Potassium Chloride (KCL). Sentinel event. Concentrated KCL – multiple cases in international literature of inadvertent injection of concentrated KCL (often fatal).

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Concentrated Potassium Chloride (KCL)

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  1. Concentrated Potassium Chloride (KCL) Sentinel event

  2. Concentrated KCL – multiple cases in international literature of inadvertent injection of concentrated KCL (often fatal). • Recent NZ case involving nurse who thought that she was injecting heparinised saline, but was actually injecting concentrated KCL. 9 year-old boy arrested (was resuscitated).

  3. Root causes of KCL incidents • Look alike ampoules – KCL ampoules look like other low risk ampoules • Storage of KCL • Human factors – distraction, poorly organised environment, lighting, high workload

  4. Concentrated KCL: the problem "The way to prevent tragic deaths from accidental intravenous injection of concentrated KCl is excruciatingly simple -- organizations must take it off the floor stock of all units. It is one of the best examples I know of a 'forcing function' -- a procedure that makes a certain type of error impossible." Lucian L. Leape, M.D. Harvard School of Public Health

  5. KCL Alert

  6. Remove KCL from wards, replace with pre-mixed bags Store KCL in red click/clack boxes away from other ampoules Store KCL in Pyxis machines Concentrated KCL: the solution

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