# 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

- **ID:** `medical/iv-kcl-concentration-exceed`
- **领域:** medical
- **类别:** config_error
- **错误码:** `ERR_IV_KCL_CONC`
- **验证级别:** ai_generated
- **修复率:** 87%

## 根因

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。

## 版本兼容性

| 版本 | 状态 | 引入 | 弃用 |
|------|------|------|------|
| Alaris PCU v9.2 | active | — | — |
| Baxter Spectrum v8.1 | active | — | — |
| ISMP Guidelines v2023 | active | — | — |

## 解决方案

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.
   ```

## 无效尝试

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