IV Potassium Given Epidurally: Getting to the "Route" of the Problem

Nurses Safety

Published

Specializes in Education, FP, LNC, Forensics, ED, OB.
A nurse accidentally infused intravenous potassium chloride injection by the epidural route to a post-operative hypokalemic patient. She intended to connect the IV tubing from the potassium chloride minibag to the maintenance IV infusion line via a Y-site port. Instead she connected the potassium infusion to a Y-site located on the patient's epidural line through which fentanyl and bupivacaine were infusing. The patient received a total of 20 mEq of potassium in 50 mL of solution over 2 hours, after which the nurse disconnected the minibag

http://www.medscape.com/viewarticle/533484?src=mp

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Specializes in many.

Siri,

Sorry, I couldn't open the link. Would love to read more about this so I could avoid the problem in the future though.

ragingmomster

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Specializes in Education, FP, LNC, Forensics, ED, OB.

hello, ragingmomster,

you might need to go to medscape.com and register to view the article.

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Specializes in NICU, PICU, PCVICU and peds oncology.
hello, ragingmomster,

you might need to go to medscape.com and register to view the article.

the other thing would be to go right to the source. http://www.ismp.org/ is the website for safe medication practices. they have an archive of errors that have been reported, an analysis of factors contributing to the error and recommendations for preventing them in the future. they also have a newsletter that you can subscribe to that i find to be very good.

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Specializes in Hemodialysis, Home Health.
The other thing would be to go right to the source. http://www.ismp.org/ is the website for safe medication practices. They have an archive of errors that have been reported, an analysis of factors contributing to the error and recommendations for preventing them in the future. They also have a newsletter that you can subscribe to that I find to be very good.

Great link, Jan ! Thanx for sharing ! :)

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I didn't see the story on either site.

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Specializes in Education, FP, LNC, Forensics, ED, OB.

If you are having difficulty viewing the article, you can go to www.medscape.com/nurses and register. It is a free sign-up.

On the other site, you will need to search for the article, but should be able to find it.

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Specializes in cardiac/critical care/ informatics.

Epidurals in our hospital are on thier own pump we have one kind of pump that is used only for epidural, different iv pumps for iv. Also the tubing is tinted yellow, and has no accessible ports in the tubing. this was done to specifically keep something like that happening.

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Specializes in NICU, Infection Control.

http://www.ismp.org/Newsletters/acutecare/articles/20060406.asp

Try this link.

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Specializes in Education, FP, LNC, Forensics, ED, OB.

Thank you, prmenrs;)

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