Student nurse gave IV pot, patient died.

MaryAnn_RN · Oct 12, 2008

its my understanding that potassium is avauilable in ICU in concentrated vials.

In my Trust we have potassium in the HDU, ICU and Theatres, don't know about A&E. I work in ICU. We have small prediluted bags of potassium, 1mmol per ml, each bag contains 60mmols. They are used for infusions into central venous lines.

We also have ampoules of concentrated potassium which are kept in the CD cupboard. This is used when pts are on haemodiafiltration.

Whisper · Oct 12, 2008

I can't believe that this was allowed to happen, I work with students and train new staff nurses to give IVs, third year students we'll let mix and draw up drugs under supervision, even set the IVAC, but they are not allowed to touch, a patients venflon. You have to be qualified at least six months before you can start the iv pack.

We store un diluted K+ on the ward, but it is kept in our CD cupboard, and even that is now in a small bag which does need further dilluitng, not the old style glass vials we used to have.

It seems unbelieveable that such a mistake could happen. Even when we've been really busy, I've never left a student mixing an IV and they all know they can't give them.

My trust had an incident with K+ years ago and spent a fortune on new pumps, because a student, removed an Iv bag from a pump without closing the gate, and the bag ran through stat, patient very ill and spent weeks in CICU. Now all our pumps lock off when ever you open the door even if you close the gate.

I'm sure Liverpool will have serious training issues to attend to.

letina · Oct 13, 2008

I was working at this hospital (Whiston) at the time this incident happened. You'd think it would have been "hot gossip" at the time wouldn't you? But no......it was as if nothing had happened. No-one talked about it. In fact, most of us found out about it from the media.

Talk about burying your head in the sand :icon_roll

I wonder to this day if any lessons have been learned

Silverdragon102, BSN · Oct 13, 2008

I just think it is so sad that we have to wait for a serious incident before we act.

Same with a lot of other things not just in nursing. I remember where I used to work in the UK was a busy 6 lane ring road (3 each way) with traffic driving 40 mph and a pelican crossing, given up the amount of people injured on the crossing but council wont put lights up because no one has died yet :eek:

cheshirecat · Oct 13, 2008

But I still cannot understand why the student nurse gave the pottasium IV. Surely she knew she should not do it?

ZippyGBR, BSN, RN · Oct 16, 2008

In the UK student nurses do not give IV drugs at all.
Cannot imagine what this student nurse was thinking of.

it's a matter of local policy, many places have removed the mystique and quite frankly male bovine excrement around IV drug adminstration ...

however quite what IV potassium concentrates were doing outside of pharmacy asepctics or Critical care / CCU i don't know ...

cheshirecat · Oct 16, 2008

No mystique, just safety as this case demonstrates.

What planet are you on?

ZippyGBR, BSN, RN · Oct 17, 2008

I can't believe that this was allowed to happen, I work with students and train new staff nurses to give IVs, third year students we'll let mix and draw up drugs under supervision, even set the IVAC, but they are not allowed to touch, a patients venflon. You have to be qualified at least six months before you can start the iv pack.

what is your evidence base for this statement ?

what magically happens when you've been qualified 6 months ?

Nursing needs to get a grip of pointless meaningless rituals and the creation of 'special status ' for what should be core skills

Nursing tneeds to get a grip on the means and methods of drug adminstration, i find it extremely frustrating that many nursesi nthe UK do not see the irony of the ritual and bluster associated with IV drug adminstration and peripheral cannulation as the bad thing it is nad how much damage is done to patient care because of these poor attitudes towards what should be a core skill.

the alternative is that nursing will manage to disappear up it's own rear end as other professions without such attitudes get mission creep ... (e.g. Paramedics and ECPs in the emergency department, ODPs moving into critical care areas instead of RNs once they've finally ousted the last bastions of the scrubdogs, Respiratory Physios making a move to create the crzy situation that leftpondia has with RTs doing core nursing roles becasue they have something to do with the respiratory tract ... ) - while it won't save the organisation money ( unleike the US situation) they may well decice it's in the benefit of the trust for other factors

letina · Oct 17, 2008

however quite what IV potassium concentrates were doing outside of pharmacy asepctics or Critical care / CCU i don't know ...

Can't speak for UK policies any more as I've been in the US for a while now. But even on regular Med/Surg units here, the RN gives IV potassium, as per the unit protocol, if the patient's labs indicate the need.

I think what went wrong here (apart from it being a student who administered it) was she gave it as an IV push instead of a dilute over the required number of hours.

allnurses Guide · Oct 17, 2008

It would be very unusual for IV potassium to be in a ward environment in the UK, in my hospital, it is treated as a controlled drug and recorded in the controlled drugs book in ICU / CCU and if a patient requires a higher concentration that what is found in the standard IV bags they need to go to a critical care area.

Silverdragon102, BSN · Oct 17, 2008

As this incident goes back 5 years then who knows what the current storing of potassium was unless you worked there and knew it.

Valerie Salva, BSN, RN · Oct 17, 2008

Only one lecture on IV drug administration, and it wasn't mandatory?

In my program, we studied IV drugs for three months, plus I had a full semester of pharmacology. I also had to take a semester long class on drug calculations- and I only have an associate's degree! This nurse was in a BSN program!