Focus on patient safety - "Accidents related to a high-risk medicinal product. Who says potassium (KCI) says maximum vigilance"

Context 

Although corrective measures have been implemented by the National Agency for Medicines and Health Products Safety (ANSM), potassium chloride for injection and even for oral administration continues to be used incorrectly. These errors are among the Never Events that should never happen. 

Numerous guidelines and actions to improve the potassium chloride circuit have been published. Despite these guidelines, ten care-related serious adverse events concerning adverse events related to KCl have been reported in the serious adverse events database. This figure obviously underestimates the reality, as seen in the 150 serious adverse events registered by the ANSM since 2018.

Objective 

By sharing this feedback from professionals faced with these care-related serious adverse events, this information sheet can be used to alert and raise awareness among medical teams as to the continuing occurrence of serious adverse events related to accidental administration of KCl, and also, to prevent it happening in order to mitigate the consequences of drug errors, by providing healthcare professionals with additional information on high-risk medicinal products. 

So it doesn’t happen again 

This information sheet highlights incorrect potassium use in any form. It also recalls the guidelines and actions for improving the KCl circuit. 

Analysis of the deep-rooted causes and defective barriers reveals under-evaluation of the risk inherent to potassium chloride prescription. 

Medicinal products containing KCl should therefore be regularly assessed in terms of organisation by all actors in the healthcare sector.  

• Always opt for the oral potassium form where the clinical situation allows it.
• Always dilute the potassium for injection (KCl) on administration.