Potassium Chloride Injections May Be Confused For Other Products, ISMP Warns

Confusion over potassium chloride injections have led to several patient deaths, including the deaths of at least three infants, the ISMP warns.

A group of medication experts are warning about dosing errors with potassium chloride injections, which have become increasing common and resulted in some patient deaths, since the containers may be confused for other medications with similar packaging.

The Institute for Safe Medication Practices (ISMP) issued a safety alert May 17, warning that the new packaging for potassium chloride creates the possibility for potentially deadly medication errors.

Potassium chloride for injection concentrate (2 mEq/mL), manufactured by B. Braun, is now packaged in a 250 mL EXCEL container plastic bag with blue and red labeling. This is a pharmacy bulk package and should only be used in a pharmacy admixture service where it is restricted to the preparation of admixtures for intravenous infusions.

Until now, B. Braun has supplied potassium chloride for injection in a 250 mL glass bottle with a hanger and has been the only company in recent years to provide a 250 mL glass bottle presentation.

The glass bottling was discontinued in the early part of 2022, and a current shortage of potassium chloride for injection led B. Braun to the decision to use 250 mL plastic bags.

The ISMP has received complaints from pharmacists and pharmacy technicians concerned about this product being mistaken for IV infusion bags that have the same appearance, which are manufactured by B. Braun and other companies. Several other medications are labeled with similar blue and red print, such as sterile water for injection, or premixed heparin, premixed potassium chloride in 5% dextrose injection, hypertonic sodium chloride injection, or HESPAN.

Potassium chloride is highly concentrated and can stop a patient’s heart if it is accidentally administered undiluted, which could lead to the death of a patient.

Prior medication errors with potassium chloride in glass bottles have been reported and similar situations may occur with plastic bottles, ISMP warns.

One report indicated a bulk package was accidentally infused directly into a patient’s IV line without being diluted, killing the patient. In another case, the potassium chloride was used to dilute heparin for infant umbilical lines in the neonatal intensive care unit. This resulted in the deaths of three infants.

Since the incidents with the glass containers occurred, a requirement was placed on the medication for the cap of the container and the overseal to have the words “Must Be Diluted” printed on it. However, there is no cap or overseal with the plastic bag packaging.

The ISMP urges pharmacies continuing to use the products to ensure it is never distributed outside of the pharmacy. Cases should be immediately opened and other warning labels attached to the overwrap on all bags, and pharmacies should ensure proper barcode scanning is done at all times when the medication is administered.