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December 12, 2019: Change Management in Response to Preventable Tragedies

In January 2019, ISMP Canada published a safety bulletin about 2 pediatric deaths related to the use of concentrated electrolyte solutions. One incident involved the inadvertent use of concentrated potassium phosphate solution to flush an intravenous line; the other involved a preparation error that resulted in the patient receiving 10 times the required amount of potassium chloride intravenously. Intravenous administration of a concentrated potassium solution (≥ 2 mmol/mL) is considered to be a pharmaceutical "never event". "Never events" are defined as "patient safety incidents that result in serious patient harm or death, and that can be prevented by using organizational checks and balances." The internal analysis that followed these incidents led to several key changes at the hospital involved. The current bulletin not only outlines key strategies that were used to effect this change, but also describes how those strategies were successfully implemented.  Read more ...