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Reduce Adverse Drug Events Involving Electrolytes:
Remove All Concentrated Electrolytes from Floor Stock

Concentrated electrolytes pose a fatal threat to patients. When they are available on a patient care unit, it is far too easy for someone to accidentally administer the concentrated material without first diluting it in solution, especially during an emergency. Such an error often leads to an immediate and severe reaction, including death. Remove all concentrated electrolytes from floor stock and never dispense them from the pharmacy.


Tips
  • Remember that ALL concentrated electrolytes can cause serious harm, not just potassium, which is removed most often.
  • Check routinely for the presence of concentrated electrolytes on patient care units, as sometimes they may slip through the system.
  • Secure any concentrated electrolytes that must be kept in emergency carts or boxes by placing them in an extra box, so that staff must take an extra step to access them.
  • Use pre-mixed solutions for intravenous administration of electrolytes so that staff will not need to have concentrated material.