The Pharmaceutical Journal
Vol 269 No 7208 p122
27 July 2002

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First national patient safety alert asks pharmacists to act by end of October

Pharmacists are called upon to play a key role in implementing the first patient safety alert published by the National Patient Safety Agency this week.

The alert, which was announced last month (PJ, 22 June, p861), sets out action to be taken to reduce risk to patients from intravenous administration of potassium solutions.

Chief pharmacists and pharmaceutical advisers in hospitals and primary care trusts are asked to ensure that solutions of concentrated potassium chloride are restricted to pharmacy departments and to critical care areas where the concentrated solutions are needed for urgent use.

The alert states that all supplies of potassium chloride concentrate should be made directly from pharmacies and that records should be kept in the same way as for Controlled Drugs.

Pharmacists should also remove potassium chloride concentrate from wards and clinical areas, use commercially prepared diluted potassium solution where possible, and store potassium chloride concentrate in a separate locked cupboard.

Where strong potassium solutions are used in clinical areas the preparation and administration of the drug must be checked by a second practitioner. The recommendations set out in the alert must be implemented by 31 October.

The alert follows a survey, commissioned by the NPSA between March and June of this year, on the arrangements for storage and use of potassium chloride concentrate in the National Health Service. The results of the survey indicated that concentrated solutions of potassium chloride were being stored in areas other than the pharmacy in most hospitals in the United Kingdom. In addition, most hospitals had not developed a local policy for storage and dilution of potassium solutions.

The NPSA has not insisted that concentrated potassium chloride solutions are removed from critical care areas because it says that neither critical care physicians nor pharmacists were confident that all pharmacy departments could prepare and deliver all the required dilutions of potassium solutions fast enough on every occasion.

The safety alert has been sent to all chief executives and medical directors within the NHS in England and will also be made available to Government bodies in Wales, Scotland and Northern Ireland.

The full alert is available on the NPSA website (www.npsa.org.uk).