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Potassium solutions: risks to patients from errors occurring during intravenous administration

Reference number 1051
Issue date31 October 2002
TypeAlert
This Patient Safety Alert aims to reduce the risk of accidental overdose of intravenous potassium arising from use of potassium chloride concentrate solutions and other strong potassium solutions. It also aims to ensure that seriously ill patients who urgently require intravenous potassium as part of their treatment continue to receive it promptly.


Potassium chloride concentrate solution can be fatal if given inappropriately. It is widely used and administered intravenously in diluted solutions to treat low potassium levels (hypokalaemia) in more seriously ill patients. Patients with low potassium levels may require intravenous potassium very quickly. A delay in administering this therapy could compromise patient care and risk cardiac arrest.


Reports from the UK and elsewhere have identified incidents where potassium chloride concentrate has been accidentally administered to patients with fatal results. Commonly, staff mistook potassium chloride concentrate solution for sodium chloride (normal saline) solution when reconstituting a drug for injection and thereby administered an accidental overdose of potassium.


NHS organisations should take initial action in the following areas:


  • storage and handling of potassium chloride concentrate and other strong potassium solutions;
  • preparation of dilute solutions containing potassium;
  • prescription of solutions containing potassium;
  • checking the use of strong potassium solutions in clinical areas;
  • and training staff appropriately.
Notes Although the deadline for actions has passed, this guidance remains best practice. It should be followed to help prevent future patient safety incidents.
Potassium chloride concentrate solution - Patient Safety Alert
Potassium chloride concentrate solution - Patient Safety Alert - 57 KB 1051 - Potassium chloride concentrate solution - Patient Safety Alert - 2002-10-31 - V1
Potassium chloride concentrate solution visually inpaired - Patient Safety Alert
Potassium chloride concentrate solution visually inpaired - Patient Safety Alert - 53 KB 1051A - Potassium chloride concentrate solution visually inpaired - Patient Safety Alert - 2002-10-31 - V1