Feeling Guilty

**canoehead, BSN, RN** · Nov 25, 2017

Normal K here is 3.5, so it wasn't a big error, but it could have been. You'll be more conscious of K from now on.

KelRN215, BSN, RN · Nov 26, 2017

Why would you give a potassium bolus for a K+ of 3.4? That's not critically low. What did the PRN order say?

When I worked in the hospital, the policy was no IV potassium boluses unless the K+ was

Goofaroo · Nov 26, 2017

The potassium bolus protocol is ordered for below 3.5

KelRN215, BSN, RN · Nov 26, 2017

The potassium bolus protocol is ordered for below 3.5

When you say bolus are you talking about just a PRN PO dose?

And what is the frequency of the order? 80 mEq of KCl in a day would be a lot. 40 mEq is a lot in a single dose. Typically you shouldn't give more than 20 mEq in a single dose.

Potassium Chloride - FDA prescribing information, side effects and uses

Goofaroo · Nov 26, 2017

It's 40 meq iv over a few hours with ns runs at like 25 ml per hr and the ns at 30 i don't remember exactly off the top of my head

Sour Lemon · Nov 26, 2017

Why would you give a potassium bolus for a K+ of 3.4? That's not critically low. What did the PRN order say?
When I worked in the hospital, the policy was no IV potassium boluses unless the K+ was
We do this frequently with patients who are expected to drop for some reason ...or patients who may not be able to take PO. It might be unusual in some places, but it's not unheard of.

Penelope_Pitstop, BSN, RN · Nov 26, 2017

Let's say you *had* recalled the order. Would it have been necessary to administer?

I know the order was for a K+ below 3.5, but why was the K+ below 3.5 for this patient? Diuresis or other sort of fluid losses, for example? It sounds like it was well on the way to correction.

Also, the least invasive method is best if it works. A lot of patients wouldn't respond to 40 mEq PO x 1 if they had a K+ level less than 3. So repeating that could over-correct the hypokalemia. (And correcting hyperkalemia is a lot less...palatable). And IV potassium burns and can cause tissue damage if infiltrated.

So, what I would have done would be notify the doc and ask to have the order changed to be more specific or to be discontinued all together.

Been there,done that, ASN, RN · Nov 26, 2017

Whatever the order was for, is a moot point. The fact is, you asked for an order, got it and then didn't catch it.

THAT is a huge error.

Ruby Vee, BSN · Nov 26, 2017

Whatever the order was for, is a moot point. The fact is, you asked for an order, got it and then didn't catch it.
THAT is a huge error.

I agree. And to those who are second guessing whether or not the patient really needed the potassium -- that wasn't the issue. The issue is that the K+ was rechecked, came back low and the OP had an order to treat it . . . but she spaced it. Had she evaluated the situation and the order and perhaps asked the charge nurse or some other senior nurse what to do, that would be different. But she didn't. She just forgot all about it. That is an error.

To the OP -- we all make errors. All of us. I've made the exact error you did and got lambasted for it by the provider. And she was right -- I SHOULD have replaced the potassium. Especially since the patient was getting diuretics. The OP's error seemingly caused to harm to the patient, but my patient could have had cardiac arrhythmias due to my oversight. Hopefully, you've learned from the error and won't make that one again. Once you've caught the error, admitted to it, done what you can to save the patient from consequences of your error and informed your manager that you made the error AND understand the potential ramifications AND are profoundly sorry, the next task is to forgive yourself. That's probably the hardest task of all.

We all make errors. The measure of a nurse isn't in whether or not she's made an error, but it what she does AFTER she makes the error.

dontbetachy90, BSN, RN · Nov 26, 2017

It depends on the plan of care and the patient, and definitely the provider as well. I work in cardiac intermediate and we often heavily diurese people on Bumex gtt's; these patients sometimes receive scheduled potassium AND PRN replacement practically around the clock, because they deplete so rapidly. Practically all of our cardiac patients have potassium/magnesium sliding scales (some are renal doses of course); sometimes we have patients (sometimes cardiac, sometimes post-op) who have target electrolyte ranges that are at the higher end of the "normal" range. Just depends! :)

dontbetachy90, BSN, RN · Nov 26, 2017

Here's the thing; yes, you missed a lab value, and yes, missing electrolyte replacement CAN be a critical error in some patients. A potassium of 2.7 can certainly cause some problems for your patient so it is important to follow up, especially if the patient is being diuresed, or has something else going on that may deplete their electrolytes. Thankfully the redraw came back at 3.4, which is acceptable!

It's normal to feel bummed that you missed something, but remember that you are only human, and a very busy human nurse at that, and sometimes we miss things. That's just the way it is. Some will say, "doesn't matter, you missed it and that's an error," while others will say, "it's a 24h operation, the next shift can replace the potassium." I wouldn't say that either points are entirely wrong (I know that is probably unhelpful! But this is real life we're talking, here!) All you can do is apologize, move on, and try to keep an eye out for those lab values next time.

I am fortunate enough to work with some forgiving nurses, day and night shift alike. Our unit is often very busy so if it's not a critical issue, I try to give my coworkers as much slack as I see reasonable. Personally, when I know I have a lab to keep an eye out for, I will write it down on my brains in red ink so I don't forget! Sometimes that isn't even enough though. We're all human!