Promoting oral potassium administration in a tertiary care hospital: An eleven-year study

[Inability of hospital computerised physician order entry systems to secure the use of concentrated potassium intravenous solutions]

OBJECTIVES

To determine whether hospital computerised physician order entry (CPOE) systems contribute to securing intravenous potassium chloride (KCl) prescriptions with reference to the recommendations issued by French healthcare agencies.

METHODS

We sent a questionnaire to the members of the Association pour le Digital et l'Information en Pharmacie.

RESULTS

More than three quarters of the 84 responses received involving 23 CPOE systems indicate that it is possible to: prescribe an ampoule of concentrated potassium chloride 10% 10mL intravenously without any diluents (80%); prescribe 4g of KCl in a bag of 500mL of NaCl 0,9% (98%); prescribe a solution that contains 6 grams of KCl per liter (94%); prescribe the administration of an injectable ampoule orally by means of a free text comment (83%). Nearly half of the responses indicate that it is possible to prescribe: concentrated KCl ampoules as administration solvent (50%); an injectable vial to be administered by oral route (52%).

CONCLUSION

At least 23 hospital CPOE systems are unable to secure the prescriptions of injectable KCl. This finding lifts the veil on an unthought, namely the role of CPOE systems in securing high-risk medications. In order to solve this problem, it should be mandatory that health information technology vendors pay particular attention to these drugs. With regard to injectable KCl, the utilisation of a dilution vehicle, maximum concentration and maximum infusion flow rate are the first four constraints to be satisfied.

Potassium overdose using an oral solution: Potassium element expressed in grams as a packaging flaw contributing to medication error

Drug packaging contributes to the harm-benefit balance of a treatment. Poorly designed packaging can lead to drug misuse with serious consequences. We report a potassium double dose medication error concerning an oral solution. It was triggered by a packaging flaw related to the dosage indicated on the box, expressed for both potassium salt and elemental potassium. Standardizing the units used on packaging and for prescriptions, by using millimoles, could be a solution to avoid this type of medication error.