Hospital Pharmacist
Vol 9 No 6 p155
June 2002

News summary

Related websites
National Patient Safety Agency (NPSA) (www.npsa.org.uk)

Safety body issues warning on potassium chloride injections

The first patient safety alert to be issued by the National Patient Safety Agency (NPSA) will recommend that ampoules of concentrated potassium chloride injections should be withdrawn from general wards in hospitals and replaced with diluted forms of the drug.

According to Susan Williams, NPSA joint chief executive, the agency is also working with manufacturers of potassium chloride products to ensure the availability of a wider range of diluted products (The Pharmaceutical Journal 2002;268:861).

The NPSA is taking these steps in response to the results of a pilot study of adverse event reporting carried out in 28 NHS trusts, in which three patients were reported to have died due to errors in the use of potassium chloride.

Many hospitals already have in place safeguards against the inappropriate use of concentrated potassium chloride injections. These include the designation of potassium chloride ampoules as "Controlled Drugs".

Miss Alison Ewing, clinical director of pharmacy at Royal Liverpool University Hospital welcomed the decision to publish the safety alert. She said: "I think it is good that everyone now will have one set of rules to work to." She was also pleased because the withdrawal of concentrated potassium chloride from wards means that the use of the products will now be under the auspices of the pharmacy department.

The safety alert had not been published as HP went to press.