1. Concentrated Potassium Chloride (KCL) Sentinel event

2. Concentrated KCL – multiple cases in international literature of inadvertent injection of concentrated KCL (often fatal). Recent NZ case involving nurse who thought that she was injecting heparinised saline, but was actually injecting concentrated KCL. 9 year-old boy arrested (was resuscitated).

3. Root causes of KCL incidents 1.Look alike ampoules – KCL ampoules look like other low risk ampoules 2.Storage of KCL 3.Human factors – distraction, poorly organised environment, lighting, high workload

4. Concentrated KCL: the problem " The way to prevent tragic deaths from accidental intravenous injection of concentrated KCl is excruciatingly simple -- organizations must take it off the floor stock of all units. It is one of the best examples I know of a 'forcing function' -- a procedure that makes a certain type of error impossible." Lucian L. Leape, M.D. Harvard School of Public Health

5. KCL Alert

6. Concentrated KCL: the solution 1.Remove KCL from wards, replace with pre-mixed bags 2.Store KCL in red click/clack boxes away from other ampoules 3.Store KCL in Pyxis machines