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Pharmacists warn of deadly preventable medical error due to new drug packaging

A medical products company announced new way of packaging potassium chloride for injection concentrates – new packaging of this concentrate has been the in the past associated with at least 3 infant fatalities. What was once stored in a glass bottle is now given in an Excel plastic bag, that looks similar to an IV infusion bag. Pharmacists are concerned about the potential risk for the concentrated potassium chloride to be mistaken for IV infusion bags. Potassium chloride for injection in the bag is highly concentrated and can stop a patient’s heart if accidentally administered undiluted, resulting in a fatal outcome.

Product Safety Bulletin: B. Braun Corporation

The Institute for Safe Medical Practices has recommended practitioners take the following steps to prevent potentially fatal medication errors:

  1. Ensure that only the pharmacy can purchase, store, and utilize this product. Product should never be distributed to any area outside of the pharmacy. The manufacturer has labeled the shipping case, “Pharmacy Bulk Package. For Pharmacy Use Only.”
  2. Upon receipt of the potassium chloride for injection concentrate bags, pharmacy staff should immediately open the case and affix large, bold, auxiliary warning labels to overwrap on both sides of all bags. Pharmacists should create additional labels so that warnings can be applied to both sides of the container. When ready to use, remove the overwrap and affix warning labels to both sides of the bag.
  3. Create proper barcodes to scan when using the product to prepare compounded sterile preparations. To help identify any containers that might be mistaken to be potassium chloride for injection concentrate, all premixed medications in IV bags that have been removed from their shipping cartons should be scanned before being used or dispensed.

If you or a loved one is administered potassium chloride or any other drug, do not hesitate to ask questions of your medical providers. Patients and their family members are often their own best advocates for preventing harmful or even deadly medical mistakes.

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