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Year : 2012  |  Volume : 56  |  Issue : 1  |  Page : 90-91  

Potassium chloride: A high risk drug for medication error

1 Department of Anaesthesiology, G. R. Medical College, Gwalior, Madhya Pradesh, India
2 Department of Pharmacology, G. R. Medical College, Gwalior, Madhya Pradesh, India

Date of Web Publication29-Feb-2012

Correspondence Address:
Dilip Kothari
2 A, J.A. Hospital campus, Gwalior 474009, Madhya Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0019-5049.93357

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How to cite this article:
Kothari D, Kothari S, Agrawal J. Potassium chloride: A high risk drug for medication error. Indian J Anaesth 2012;56:90-1

How to cite this URL:
Kothari D, Kothari S, Agrawal J. Potassium chloride: A high risk drug for medication error. Indian J Anaesth [serial online] 2012 [cited 2020 Oct 22];56:90-1. Available from: https://www.ijaweb.org/text.asp?2012/56/1/90/93357


Despite the improved system of manufacturing, packaging and delivery, 44,000-98,000 patients die each year as a result of medical error. [1] Potassium chloride has been involved in many fatal incidences in the past. Between 1996 and 1998, the Joint commission for Accreditation of Healthcare Organizations (JCAHO) found 10 deaths due to wrong administration of potassium chloride, and six cases of these were due to identical labels. The Commission recommended that concentrated potassium chloride should not be made available outside the pharmacy unless appropriate specific safeguards are in place. [2],[3] Recently, another near fatal report of medication error with potassium chloride has been published. [4] The 12 points recommendations [Table 1] about pharmacist's and multidisciplinary professional's role in preventing medication error with potassium chloride have been published in the literature. [5] Look alike or sound alike names, similar looking vials or ampoules, same colour labels, identical packing, improper handling and, haste or human mistake in administration have all been identified as the reason for medication errors. [6] Various organizations like the Institute for Safe Medication Practices (ISMP), Food and Drug Administration (FDA) and, Institute of Medicine (IOM), have issued guidelines for the safe practice of medication to the patients. [7] In India, small scale manufacturers do not adhere to these guidelines because of various reasons like non availability of new technology, absence of strict compliance and severe punishment to defaulters. In conclusion, potassium chloride should be handled with utmost care, should not be available on routine drug counters and should be made available on demand from the drug store only.
Table 1: Recommendation for reducing potassium related medication error[5]

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   References Top

1.Kohn LT, Corrigan JM, Donaldson MS, editors. Institute of Medicine Report: To Err is Human: Building a safer health system. Washington, DC: National Academy Press; 1999. Available from: http://bob.nap.edu/html/to err is human/. [last accessed on 2004 Sept].  Back to cited text no. 1
2.Cohen MR. Ongoing potassium chloride concentrate errors kill patients: Issue of cost versus care? Hosp Pharm 1994;31:187-8.  Back to cited text no. 2
3.Patients safety alerts. Medication error prevention: Potassium chloride. Int J Qual Health Care 2001;13:55.  Back to cited text no. 3
4.Shah HD, Shah M. A case of look-alike medication errors. Indian J Pharmacol 2011;43:482-3.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.David U, Sylvia H. Medication safety alerts. CJHP 2002;55:278-80.  Back to cited text no. 5
6.Kothari D, Gupta S, Sharma C, Kothari S. Medication error in anaesthesia and critical care: A cause for concern. Indian J Anaesth 2010;54:187-192.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Martin DE. Medication error persist: Summit addresses intravenous safety. APSF Newsletter 2008; 23:37-9.  Back to cited text no. 7


  [Table 1]

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