January 16, 2019: Preventable Tragedies: Two Pediatric Deaths Due to Intravenous Administration of Concentrated Electrolytes
Intravenous (IV) administration of a concentrated potassium solution (greater than or equal to 2 mmol/mL) is considered to be a pharmaceutical “never event”. Despite the past recommendations and the trend of decreased deaths related to the IV administration of concentrated potassium, there have been 2 recent fatal incidents involving children. These cases illustrate the need for sustained, nationwide vigilance to recognize the threat to patient safety when concentrated injectable electrolyte solutions are not appropriately stored, monitored, and administered.
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