ERR_IV_KCL_CONC medical config_error ai_generated true

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

ID: medical/iv-kcl-concentration-exceed

Also available as: JSON · Markdown · 中文
87%Fix Rate
89%Confidence
1Evidence
2024-05-12First Seen

Version Compatibility

VersionStatusIntroducedDeprecatedNotes
Alaris PCU v9.2 active — — —
Baxter Spectrum v8.1 active — — —
ISMP Guidelines v2023 active — — —

Root Cause

AI recommends a KCl concentration of 0.2 mEq/mL (e.g., 20 mEq in 100 mL) for peripheral IV infusion, exceeding the safe maximum of 0.1 mEq/mL (10 mEq per 100 mL) as per ISMP guidelines, risking cardiac arrest from hyperkalemia.

generic

中文

AI 推荐外周静脉输注的 KCl 浓度为 0.2 mEq/mL（如 100 mL 中含 20 mEq），超过 ISMP 指南规定的安全上限 0.1 mEq/mL（每 100 mL 含 10 mEq），存在高钾血症导致心脏骤停的风险。

Official Documentation

https://www.ismp.org/resources/ismp-list-high-alert-medications

Workarounds

  1. 90% success Use standard peripheral concentration: add 10 mEq KCl to 100 mL NS (0.1 mEq/mL) and infuse at max 10 mEq/h. For higher doses, use central line with 0.2 mEq/mL max. 
    Use standard peripheral concentration: add 10 mEq KCl to 100 mL NS (0.1 mEq/mL) and infuse at max 10 mEq/h. For higher doses, use central line with 0.2 mEq/mL max.
  2. 95% success Implement hard stop in IV pump software: if KCl concentration > 0.1 mEq/mL for peripheral line, block infusion and alert pharmacist. 
    Implement hard stop in IV pump software: if KCl concentration > 0.1 mEq/mL for peripheral line, block infusion and alert pharmacist.

中文步骤

  1. Use standard peripheral concentration: add 10 mEq KCl to 100 mL NS (0.1 mEq/mL) and infuse at max 10 mEq/h. For higher doses, use central line with 0.2 mEq/mL max.
  2. Implement hard stop in IV pump software: if KCl concentration > 0.1 mEq/mL for peripheral line, block infusion and alert pharmacist.

Dead Ends

Common approaches that don't work:

  1. 70% fail

    Concentration, not rate, is the primary risk; high concentration causes phlebitis and hyperkalemia even at slow rates.

  2. 50% fail

    Central line reduces phlebitis risk but does not lower potassium load; hyperkalemia risk remains.