# AI instructs a nurse to administer IV potassium chloride at a concentration exceeding 0.1 mEq/mL, risking fatal hyperkalemia and cardiac arrest

- **ID:** `medical/incorrect-dilution-of-intravenous-potassium-chloride`
- **Domain:** medical
- **Category:** protocol_error
- **Error Code:** `IV-POTASSIUM-CONCENTRATION-ERROR`
- **Verification:** ai_generated
- **Fix Rate:** 92%

## Root Cause

IV potassium chloride must never be administered undiluted or at concentrations above 0.1 mEq/mL (or 10 mEq per 100 mL) due to the risk of rapid serum potassium elevation causing cardiac arrhythmias; standard practice requires dilution in at least 100 mL of compatible fluid.

## Version Compatibility

| Version | Status | Introduced | Deprecated |
|---------|--------|------------|------------|
| ISMP Guidelines for Safe IV Potassium Administration 2023 | active | — | — |
| FDA Drug Safety Communication 2022 | active | — | — |

## Workarounds

1. **Use a smart IV pump with dose-error reduction software (DERS) that has a hard limit for potassium concentration (e.g., 0.1 mEq/mL max) and alarms if exceeded.** (95% success)
   ```
   Use a smart IV pump with dose-error reduction software (DERS) that has a hard limit for potassium concentration (e.g., 0.1 mEq/mL max) and alarms if exceeded.
   ```
2. **Always dilute each 10 mEq of KCl in at least 100 mL of compatible IV fluid (e.g., normal saline or D5W) and label the bag clearly with the concentration.** (90% success)
   ```
   Always dilute each 10 mEq of KCl in at least 100 mL of compatible IV fluid (e.g., normal saline or D5W) and label the bag clearly with the concentration.
   ```
3. **Use a premixed KCl solution from the pharmacy (e.g., 20 mEq in 1000 mL) for routine maintenance to avoid compounding errors.** (85% success)
   ```
   Use a premixed KCl solution from the pharmacy (e.g., 20 mEq in 1000 mL) for routine maintenance to avoid compounding errors.
   ```

## Dead Ends

- **** — IV push of undiluted KCl can cause instantaneous cardiac arrest; the maximum rate of infusion is 10 mEq per hour via a peripheral line. (95% fail)
- **** — The concentration becomes >0.1 mEq/mL, which exceeds safe limits; alternative strategies like using a central line with lower concentrations should be used. (80% fail)
- **** — Incomplete mixing can result in a bolus of high-concentration KCl being infused, causing toxicity. (70% fail)