{
  "id": "medical/iv-kcl-concentration-exceed",
  "signature": "AI instructs a nurse to administer IV potassium chloride at a concentration exceeding 0.1 mEq/mL, risking fatal hyperkalemia",
  "signature_zh": "AI 指示护士以超过 0.1 mEq/mL 的浓度静脉注射氯化钾，存在致命高钾血症风险",
  "regex": "KCl.*concentration.*0\\.\\d+|potassium.*chloride.*mEq.*mL|IV.*K.*conc.*exceed",
  "domain": "medical",
  "category": "config_error",
  "subcategory": null,
  "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.",
  "root_cause_type": "generic",
  "root_cause_zh": "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。",
  "versions": [
    {
      "version": "Alaris PCU v9.2",
      "introduced": null,
      "deprecated": null,
      "removed": null,
      "behavior_change": null,
      "status": "active"
    },
    {
      "version": "Baxter Spectrum v8.1",
      "introduced": null,
      "deprecated": null,
      "removed": null,
      "behavior_change": null,
      "status": "active"
    },
    {
      "version": "ISMP Guidelines v2023",
      "introduced": null,
      "deprecated": null,
      "removed": null,
      "behavior_change": null,
      "status": "active"
    }
  ],
  "os_specific": {},
  "dead_ends": [
    {
      "action": "",
      "why_fails": "Concentration, not rate, is the primary risk; high concentration causes phlebitis and hyperkalemia even at slow rates.",
      "fail_rate": 0.7,
      "condition": "",
      "sources": []
    },
    {
      "action": "",
      "why_fails": "Central line reduces phlebitis risk but does not lower potassium load; hyperkalemia risk remains.",
      "fail_rate": 0.5,
      "condition": "",
      "sources": []
    }
  ],
  "workarounds": [
    {
      "action": "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.",
      "success_rate": 0.9,
      "how": "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.",
      "condition": "",
      "sources": []
    },
    {
      "action": "Implement hard stop in IV pump software: if KCl concentration > 0.1 mEq/mL for peripheral line, block infusion and alert pharmacist.",
      "success_rate": 0.95,
      "how": "Implement hard stop in IV pump software: if KCl concentration > 0.1 mEq/mL for peripheral line, block infusion and alert pharmacist.",
      "condition": "",
      "sources": []
    }
  ],
  "workarounds_zh": [
    "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.",
    "Implement hard stop in IV pump software: if KCl concentration > 0.1 mEq/mL for peripheral line, block infusion and alert pharmacist."
  ],
  "transition_graph": {
    "leads_to": [],
    "preceded_by": [],
    "frequently_confused_with": []
  },
  "official_doc_url": "https://www.ismp.org/resources/ismp-list-high-alert-medications",
  "official_doc_section": null,
  "error_code": "ERR_IV_KCL_CONC",
  "verification_tier": "ai_generated",
  "confidence": 0.89,
  "fix_success_rate": 0.87,
  "resolvable": "true",
  "first_seen": "2024-05-12",
  "last_confirmed": "2024-06-01",
  "last_updated": "2024-06-01",
  "evidence_count": 1,
  "tags": [],
  "locale": "en",
  "aliases": []
}