December 2006: Look-Alike Product ALERT
Concentrated Potassium Chloride (10mL) and Heparin Lock Flush Solution 10 units/mL (10 mL)ISMP Canada has received two ‘near miss’ reports describing replenishment of patient care area stock with concentrated potassium chloride instead of the intended heparin product. The packaging and labelling of the 10 mL concentrated potassium chloride product appear similar to the packaging and labelling of 10 mL heparin 10 units/mL “lock flush solution” (shown in Figure 1).
Potassium chloride is fatal if administered intravenously in undiluted form. As a result of initiatives to remove concentrated potassium chloride from patient care areas, the risk of substitution errors with these two products has been lessened. However, the risk remains in pharmacy departments.
After meeting with ISMP Canada to discuss the problem, the manufacturer, Hospira, is assessing options to enhance the distinction between the vials and cartons of the two products. In the interim, the following strategies are suggested to reduce the risk of substitution errors:
- Ensure distinct and separate pharmacy processes, including segregated storage for concentrated potassium chloride.
- Apply auxiliary labels and alerts in storage areas for concentrated potassium chloride.
