Issue 1
Preventable Tragedies: Two Pediatric Deaths Due to Intravenous Administration of Concentrated Electrolytes
This bulletin describes contributing factors and recommendations based on 2 never events where administration of concentrated injectable electrolytes resulted in fatalities. Contributing factors in the cases were that the concentrated electrolyte injectables were stocked in the patient care area without appropriate safeguards, prescription and preparation of these products were non-standardized processes, there was a lack of independent double checks, and look-alike packaging.
Key Words:
- Potassium chloride
- Potassium phosphate
- Confirmation bias
- Selection error
- Calculation error
- Mixing error
𝗦𝗶𝗱𝗲𝗯𝗮𝗿𝘀:
- New Regulations will Help Protect Canadians from Unsafe Medications and Medical Devices
- Medication Reviews in Long-Term Care Homes