Administration of electrolyte replacements must be carefully managed. If dosing is not appropriate, serum levels of electrolytes may be outside of normal ranges, which can lead to serious adverse events. Extremely low or high serum levels of some electrolytes can even lead to death. Using standardized approaches and taking extra safety precautions can help reduce the risk of adverse drug events associated with electrolyte replacement.
Changes for Improvement
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 Electrolytes
Intravenous solutions with electrolytes already pre-mixed in them are available commercially or can be prepared in the hospital pharmacy. Using these pre-mixed solutions eliminates the step of staff mixing solutions on patient care units, which has a risk of error, especially when the unit is very busy. It also eliminates the need to keep concentrated electrolytes on patient care units and therefore removes the risk of accidental administration of electrolytes in concentrated form, which is usually lethal.
Standardize Intravenous Electrolyte Solutions
When several different solutions of electrolytes are available, it is far too easy to dispense or administer a different solution than was ordered. There is little need for multiple solutions, as doses administered can be controlled by the flow rate set. Standardize each electrolyte solution to just one, to decrease the risk of selecting the wrong one.
Use Protocols for Intravenous Electrolytes
A protocol can provide a guide for clinical personnel to select the appropriate dosage quickly and accurately based on the patient’s serum electrolyte levels. Implement protocols based on clinical practice recommendations from professional boards and societies, or adopt a protocol that another organization has used successfully. The protocol should be designed so that nurses and pharmacists can initiate and manage the electrolyte dosing, which saves time for both them and physicians. Ensure that the protocol includes both the loading dose and subsequent bolus doses. Using protocols also provides more timely adjustments to dosages, which helps decrease the risk of adverse drug events to patients.
Set Dose Limits for Electrolytes
An unintentional overdose of electrolyte replacements can result in severe harm, or even death, for a patient. A maximum allowable dose for each electrolyte should be set so that a prescriber or person entering an order cannot accidentally select a dose outside the safe range. Even though each individual dose may appear to be within acceptable safety limits, the cumulative dose may be too high. Therefore, remember to set the maximum dose limits not just for each individual dose but for the amount to be given in 24 hours.
Tips
- Design computerized prescriber order entry screens so that a prescriber must review current serum electrolyte levels prior to selecting electrolyte dosages.
- Require pharmacy review of all orders and ensure that the pharmacists have access to laboratory results.
Require Use of Pumps with Intravenous Electrolytes
Programmable pumps precisely control the dose and amount of electrolyte solution delivered to a patient and are therefore safer than intravenous solution bags that are hung without a pump. Pumps control the amount of solution delivered so that inadvertent under dosing or overdosing does not occur.
Tips
Conduct Independent Double-Checks
Double-checks are a step to verify all information before a medication is administered. Electrolyte overdosing or under dosing has a very high risk of causing severe harm, or even death, to the patient. Double-checking the medication order and dosage can promote safety by ensuring that everything is correct. To be effective, each person checking the medication and information should do so independently. Checking together runs the risk that both people will make the same error. For example, one person reads an incorrect dosage and the other person agrees with it because she thinks she has heard the correct dosage.
Use Order Sets or Pre-Printed Orders for Intravenous Electrolytes
Electrolytes are often administered in intravenous solutions, with doses adjusted based on the patient’s serum levels of electrolytes measured via laboratory tests. It is important to keep serum electrolyte levels within normal ranges, to prevent severe adverse events that patients may experience when levels are out of range. By using order sets or pre-printed orders, prescribers can quickly select the appropriate dosages, and there is less risk that prescribers will select an inappropriate dosage or that staff will misinterpret the order due to handwriting in the absence of computerized ordering systems. Work with physicians to develop one set of standardized orders for all patients, rather than having multiple versions, which increase chances for error.
