The Pharmaceutical Journal
Vol 268 No 7203 p861-867
22 June 2002

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National Patient Safety Agency (www.npsa.org.uk)

Do not leave concentrated potassium chloride on wards, says safety agency

Potassium chloride solution, in its concentrated form, should be removed from all general wards in the United Kingdom and replaced by dilute products, says the National Patient Safety Agency in its first "patient safety alert" which is expected to be issued shortly.

Speaking at an NPSA conference this week, Susan Williams, joint chief executive, NPSA, said that the alert will also advise that, in areas where it is not yet possible to withdraw potassium chloride in its concentrated form, new controls over its use should be put into place. In addition, the NPSA will be working with manufacturers to ensure the availability of a broader range of dilute products and to help introduce distinctive packaging so that potassium chloride is easily identified and distinguished from other intravenous products. During a pilot study carried out by the NPSA, in which staff in 28 National Health Service trusts were encouraged to report adverse events, it was found that 31 reports, three of which reported deaths, were related to the use of potassium chloride.

Also speaking at the conference Professor Sir Liam Donaldson, chief medical officer, Department of Health, revealed that a total of 27,110 incidents had been reported during the pilot study, which has been running for about nine months period.Those involved included acute, primary care, ambulance and mental health services trusts.

"NHS staff of all grades were making reports, they were interested in participating in this scheme, and that is a big plus," said Professor Donaldson. However, the pilot study also showed that there were extensive problems with data transfer, he explained. Only about 50 per cent of computers in NHS trusts were able to communicate with NPSA computers. This resulted in large gaps in the accuracy of the data collected with 50 to 60 per cent of reports being uncoded as to the severity and likelihood of the incident reported.

Ms Williams went on to explain that staff had encountered problems with completing the complex reporting forms and that there were inconsistencies between trusts in how incidents had been categorised in terms of severity. To overcome these problems and ahead of the extension of the reporting scheme to all acute and mental health trusts by the end of this year, and PCTs by March 2003, an electronic reporting form is due to be launched in October.

The reporting form will be simplified and guidance issued on categorising errors. The form will allow information to be e-mailed directly to the NPSA.