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KCl Support

Injury due to inadvertent intravenous administration of concentrated potassium chloride (KCl) is a serious patient safety concern that has resulted in several deaths in Canadian hospitals. A significant contributing factor in many of the errors reported to date is the availability of potassium chloride concentrate in patient care areas.

The United States and the United Kingdom, with government initiatives, have already taken steps to remove concentrated KCl from patient care areas.

As part of the first Medication Safety Support Service initiative, ISMP Canada has assembled a comprehensive package to assist in the removal of KCI concentrate from general patient care areas in Ontario hospitals. The package contains the rationale, the experience of many Canadian hospitals, examples of programs in other countries, draft letters to physicians, examples for automatic substitutions, sample hospital newsletters, posters, etc. This package may be obtained by filling out and submitting the following form:

Contact Name:
Job Title:
Hospital/Site Name:

* Shipping and handling charges may apply. See Notes below.

Postal Code:
Special Instructions:



  • By submitting your request, you may be contacted by ISMP Canada periodically for follow up purposes.
  • Multiple sites of a hospital corporation should submit this form individually if more than one kit is being requested.
  • Each kit costs $80 CAD (excluding tax).

To order, please download and print the Order Form

As of 2005, ISMP Canada has published the following guidelines and recommendations for the safe administration of Potassium Chloride:

Download Priority Recommendations

How to Use ‘Failure Mode and Effects Analysis’ to Prevent Error-Induced Injury with Potassium Chloride

Pharmacists' Role in Preventing Medication Errors with Potassium Chloride


Medication Safety Support Service (MSSS) Advisory Group Organizations
  • Ontario Ministry of Health and Long-Term Care
  • Canadian Society of Hospital Pharmacists - Ontario Branch
  • Ontario Hospital Association
  • College of Physicians and Surgeons of Ontario
  • Ontario Medical Association
  • Ontario College of Pharmacists
  • Institute for Safe Medication Practices Canada
  • Registered Nurses Association of Ontario
  • College of Nurses of Ontario
  • Ontario Pharmacists’ Association


The Ontario MSSS is a Collaborative Medication Safety Initiative of ISMP Canada, the Ontario Hospital Association and the Ontario Ministry of Health and Long-Term Care.