INJECTABLE POTASSIUM CHLORIDE: AUDIT OF PRESCRIPTION AND ADMINISTRATION PRACTICES
European Statement
Patient Safety and Quality Assurance
Author(s)
Yosr Trabelsi, Leila Achour, Ikram Fezaa, Samer Sahbi, Chema Drira
Why was it done?
Never events are serious incidents generally linked to human and/or practical errors, which should never happen. Most of these events are avoidable, and are the subject of specific recommendations for the implementation of appropriate protective measures. According to ANSM (French drug safety agency), potassium chloride (KCl) is among the drugs frequently implicated in Never Events.
What was done?
The aim of this study was to assess the prescription and administration practices of injectable KCL in our hospital.
How was it done?
We carried out a 1-month prospective audit between 1 and 30 September 2024. All the prescriptions of injectable KCL were collected and evaluated by a pharmacist using a data collection form. It was divided into 2 sections: preparation and administration. The reference guideline used for this study was the 2022 ANSM recommendations. The results were analyzed using excel.
What has been achieved?
Fifty-five prescriptions were included. The compliance percentage for prescriptions and administration practices was 31.4% and 30.5 %, respectively. Calculation of total intake was compliant and the total volume of diluent was mentioned in all the prescriptions. In 62% of the prescription, the correct specific units were used and in 38.2 % of cases the correct slow infusion rate was prescribed. Nevertheless, the use of the route was inappropriate since only the IV route was prescribed due to the shortage of oral KCl. For administration, final concentration (≤4g/L) of the KCL infusion was respected in 90.9% of cases and all the preparations were labeled.
What next?
The study revealed several non-conformities, leading to the development of an improvement report. Therefore, we decided to implement a training plan about injectable KCl use to ensure patient safety.