NPSA praises chief pharmacists for response to the potassium safety
alert
Strong potassium ampoules are no longer available on general wards |
Chief pharmacists and trust managers have been praised by Professor David Cousins, head of safe medication practices at the National Patient Safety Agency (NPSA) for their response to the potassium chloride safety alert issued last summer. The alert required all ampoules
of strong potassium solutions to be removed from general wards. It also
laid down storage and training
requirements.
Professor Cousins made his
comments to Hospital Pharmacist when speaking about the results of a project
to evaluate the implementation of the safety alert, which were released
recently. For the project, researchers at the NPSA sent out questionnaires
to 195 acute hospital trusts in England and Wales. Of the 166 hospitals
who responded, 68 per cent have implemented formal safety
controls. Before the alert, the number who had such controls in place was
25 per cent.
According to Professor Cousins, the figure of 68 per cent did not represent
the full picture – for some aspects of the alert, for example storing
strong potassium chloride safely and withdrawing strong
potassium chloride ampoules from general wards, the
implementation rate was as high as 80 per cent. Areas where some trusts
need more time to get up to speed are those
associated with education and training, he added.
“This is a very good response to the alert,” he told Hospital
Pharmacist. “We
would like to do even better and we think we can. Of course we would like
to see the remaining trusts
implement the alert and we won’t rest until compliance is 100 per
cent.”
As well as assessing
implementation rates, the
evaluation exercise also
highlighted issues that stand in the way of hospitals complying with the
requirements of the alert. For example, some
hospitals thought that
implementing the controls would be time consuming and costly. According
to Professor Cousins, this is not so, and “in most cases implementing
the patient safety controls can save time and money”.
In addition, obtaining licensed high strength
potassium-containing infusions also caused problems. Professor Cousins
told Hospital Pharmacist that the NPSA has identified five proposed new
licensed
infusions. This has been done with co-operation from the pharmaceutical
industry. The five proposed new licensed syringes and infusions are:
• 50ml syringe of 1000mmol/L potassium chloride in saline
• 50ml infusion bag of 1000mmol/L potassium chloride in saline
• 500ml infusion bag of 80mmol/L potassium
chloride in saline
• 500ml infusion bag of 80mmol/L potassium
chloride in 5 per cent glucose
• 500ml infusion bag of 20mmol/L potassium
chloride in 10 per cent glucose
More information on the proposed licensed products will be sent to trust
managers and chief pharmacists at
hospitals in England and Wales during September, along with detailed feedback
on the
evaluation exercise. The latter will enable trusts to
benchmark their performance against the generic standard, according to
Professor Cousins.
A more in-depth qualitative look at implementation of the alert has been
carried out by researchers from the University of York, who visited 20
trusts selected at random. At the time of going to press, that report has
not yet been published.
Professor Cousins stressed that there was no other national
safety initiative like the
potassium chloride alert
anywhere in the world. Although many hospitals in the United States have
potassium policies, it is only federal
hospitals that are inspected. Because of the nature of the NHS, the impact
of the alert is more widespread.
Dr Richard Needle, chairman of the Royal Pharmaceutical Society’s
Hospital Pharmacists Group, expressed his satisfaction at the level of
response to this safety alert but, like Professor Cousins, would like to
see 100 per cent compliance in the near future. Dr Needle added “As
the first exercise of this nature by the NPSA, this is a reassuring and
encouraging result. Although implementation of this guidance caused difficulties
in some areas, the reduction of risk to patients by stringent
control of strong potassium will be of great benefit”.
Alison Ewing, Vice-President of the Royal Pharmaceutical Society and clinical
director of pharmacy at Royal Liverpool and Broadgreen University
Hospitals NHS Trust told Hospital Pharmacist that “The degree to
which the safety alert has been implemented is a credit to all hospital
pharmacy staff who have been involved in the process in their trusts. The
risks of errors associated with ampoules of strong potassium chloride have
been dramatically reduced and in some cases eliminated
entirely. This demonstrates the benefits that pharmacy staff bring to lowering
the risks associated with using medicines in trusts.” |
