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.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Well......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.
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?
Our policy is K at 10mEq per hour MAX. I've given up to 60 mEqs IV before over 6 hours, but we absolutely do not go over 10mEq/hr. And I work a hem/onc unit. We have central lines everywhere!
That is way too fast. Potassium should be given at a MAX of 10mEq/hr through a peripheral line and 20mEq/hr through a central line. PO administration is actually the best way to give potassium, unless of course that route is contraindicated.
Check 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.
The nurse that gave me report was there when I caught the error it was a mistake, she felt awful about it.[/quote']
Do 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.
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.
Esme12, ASN, BSN, RN
20,908 Posts
Well......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?