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When ordering KCl in an ICU setting should the order be written
KCL I.V. Bolus
or KCl Infusion
There have been a number of recent errors due to a shift in
pharmacology dept cost cutting in which free KCl is delivered to
floors rather than premixed.
Patrick Atonna RN, BSN
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On Fri, 28 Feb 1997, patrick atonna wrote:
> PharmPK - Discussions about Pharmacokinetics
> Pharmacodynamics and related topics
> When ordering KCl in an ICU setting should the order be written
> KCL I.V. Bolus
> or KCl Infusion
> There have been a number of recent errors due to a shift in
> pharmacology dept cost cutting in which free KCl is delivered to
> floors rather than premixed.
> Patrick Atonna RN, BSN
Hello Patrick (et al),
You would think by now, after 15+ years of the Institute for Safe
Medication Practices (M. Cohen et al) reporting countless errors involving
KCl vials on the floors that this practice would be discontinued. This
"cost-cutting" is an incredibly false economy and certainly couldn't be
defended in court.
My own opinion is that the order should be written as "KCl infusion (x)mEq
in (y)ml to infuse over (z) minutes/hours." In addition, the preparation
of IV fluids outside of a Class 100 environment in a non-code situation
seems also to be outside of your typical risk-manager's comfort zone.
If there is already documentation inside your institution (incident
reports, interdepartmental communications, etc.) which demonstrates
problems with this procedure I'd recommend working to get it changed.
Just my two cents worth.
Richard Molitor, R.Ph.
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