Potassium chloride policies not evidence based
Evidence to support practices currently recommended for the safe handling of potassium chloride is completely lacking, according to research published this week (BMJ 2005;331:274).
Michelle Tubman, Alberta Research Centre for Child Health Evidence, Canada,
and colleagues conducted a systematic review of the literature evaluating
best practices for handling products containing potassium chloride in
hospitals.
The researchers identified 2,533 citations, 238 of which they deemed potentially
relevant. However, among these, they did not find any studies that evaluated
the effectiveness of currently recommended practices. Most were case reports
along with expert recommendations for preventing specific errors. “To reduce
the incidence of potassium related errors — many of which are preventable — effectively,
hospitals must go beyond investigating individual incidents and focus more on
identifying and implementing effective, systems-based improvements that are grounded
in evidence of reasonable quality,” the researchers say.
They point out that many widely endorsed practices, such as removing concentrated
potassium chloride from clinical areas and instituting pharmacy-based intravenous
admixture systems, do reflect a systems-based approach but call for urgent research
aimed at evaluating health care systems as a whole.
A spokeswoman for the National Patient Safety Agency told The Journal: “The
NPSA welcomes this debate regarding sustainable solutions to improve patient
safety associated with the use of potassium chloride concentrate solution.”
She pointed out that a recent study had evaluated the implementation of the NPSA’s
patient safety alert on the storage and handling of potassium chloride concentrate
solution (PJ, 2 July, p4). “[It] highlighted a number of factors which
influenced the rapid and comprehensive impact of this alert. Before publication,
only 32 per cent of trusts restricted the number of clinical areas holding stocks
of potassium chloride; since publication this figure has risen to 98 per cent,” she
added. |
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