need perspective- rapid administration of potassium - page 2
by VegRN 2,990 Views | 17 Comments
I am an experienced nurse and need feedback on a med error I caught. I received a patient who had a potassium level of 2.3, in checking the pump settings during handoff, I saw that the potassium was programmed to run in... Read More
- 0Jan 11, '13 by iluvivt
- 0Jan 11, '13 by sapphire18 GuideQuote from VegRNSorry, I wasn't directing that last sentence at you, but just the community as a whole. Good for you for catching and correcting that (very serious) error.
Yup, I was being careful, as I mentioned, the previous nurse programmed it incorrectly and when I received the patient I went in right away to check the drip rates and noticed it was programmed wrong.
- 0Jan 11, '13 by Esme12 Senior ModeratorWell......for most institutions.....20meq/hr in a central line only is the standard of care. However.....I have seen as high as 40meq/hr in a central line only....and that is RARE AND losely monitored in certain situations where the K+ is critically low and massive diuresis is occurring, like Diabeties insipidus and DKA with critical acidosis and hypokalemia
All patients receiving over 10meq/hr need to be on a cardiac monitor and access for immediate resuscitative equipment available.
protocol from the Bon Secours system
Correction of Critical Hypokalemia - emergency medicine updates
But regardless of the evidence saying it is OK...per se......this patient was not in an intensive care setting. You need to look at your policy at your facility. My issue is also the intent of the order was not to infuse 30 meq/45min....and certainly not on a peripheral line. Whoever did the calculation missed a decimal/number....as the infusion should have been over 3 hours. what was the order? what did the order say?
- 0Jan 11, '13 by VICEDRNCheck the administration guidelines in your facility and talk with the pharmacist. I would seriously doubt that that is an acceptable choice for admin rate! I would also take what you learned and educate your peer, either using the unit educator or manager as an intermediary or individually as the situation calls for.
- 0Jan 19, '13 by edmiaQuote from VegRNDo your pumps have a drug library? This high rate would have been caught by the pump if you guys had access to smart ones with programmed drugs. For example, when I give K, I find potassium in my drug library and select the concentration I'm hanging. I can adjust the mEq/hr rate of the infusion, but the pump will alarm "high rate" and ask me to override in order to run. So, if I make a mistake while hitting the buttons, I have a safety mechanism in place.The nurse that gave me report was there when I caught the error, it was a mistake, she felt awful about it.
Since this was an actual med error, I'm sure you filled out an incident report. When your facility gets enough of these, they will finally invest in smart pumps.
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