# 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`
- **Domain:** medical
- **Category:** config_error
- **Error Code:** `ERR_IV_KCL_CONC`
- **Verification:** ai_generated
- **Fix Rate:** 87%

## 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.

## Version Compatibility

| Version | Status | Introduced | Deprecated |
|---------|--------|------------|------------|
| Alaris PCU v9.2 | active | — | — |
| Baxter Spectrum v8.1 | active | — | — |
| ISMP Guidelines v2023 | active | — | — |

## Workarounds

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.** (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.
   ```
2. **Implement hard stop in IV pump software: if KCl concentration > 0.1 mEq/mL for peripheral line, block infusion and alert pharmacist.** (95% success)
   ```
   Implement hard stop in IV pump software: if KCl concentration > 0.1 mEq/mL for peripheral line, block infusion and alert pharmacist.
   ```

## Dead Ends

- **** — Concentration, not rate, is the primary risk; high concentration causes phlebitis and hyperkalemia even at slow rates. (70% fail)
- **** — Central line reduces phlebitis risk but does not lower potassium load; hyperkalemia risk remains. (50% fail)