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 over 90 minutes, the patient had received half the bag, 30meq in 45 minutes in a peripheral IV. I stopped the drip, checked her tele rhythm and notified the Md.
I work at a teaching hospital, the doctor (an intern) and later the oncoming nurse seemed to not be concerned. The nurse that incorrectly programmed the pump, myself and another colleague were very concerned about arrhythmias and phlebitis. I suppose experience level could be a factor in the differencing reactions but I am wondering what you all think.
Thanks so much!
I would definitely get nursing involved in this. Check your own policy first though to find out exactly what it is and how many meq they will let you deliver on med.surg,tele and ICUs,etc. The next thing I notice is that putting 60meq in 500 ml is a risky pharmacy practice. Many recommend not to exceed 40 meq in 500ml It is much better to have several small mini bags and and or a low meq amt in a larger volume if needed. I think the ISMP has a warning about this..let me look around a bit. As I said before the incorrect administration of potassium has caused more death than any other IV medication. That is why in the US most hospitals have totally removed KCL and other potassium vials out of the hands of the nurse and back to the pharmacist to dispense. Too many patients died when nurses had access to the vials.
Last edit by iluvivt on Jan 11, '13