Contact Directors of Pharmacy
Attention: Directors of Pharmacy
Important Invitation: ISMP Canada Medication Safety Support Service
Implementing System Safeguards to Prevent Error-Induced Injury with
Concentrated Potassium Chloride
You have recently been notified through your CEO and/or the Pharmacy Connection journal of OCP, about a new Medication Safety Support Service available to Ontario healthcare facilities. This service is a joint initiative of the Ontario Ministry of Health and Long Term Care, the Ontario Hospital Association and the Institute for Safe Medication Practices, Canada (ISMP Canada). The first focus of the Support Service is assistance to Ontario hospitals to implement strategies and safeguards for the prevention of patient injury from errors with concentrated potassium chloride.
Injury due to inadvertent intravenous administration of concentrated KCl has resulted in several deaths in Ontario hospitals. A significant contributing factor in many of the errors reported to date is the availability of KCl concentrate ampoules or vials in patient care areas. This continues to be an issue in Ontario hospitals.
As part of this service, we are offering presentations to learn about the rationale for changes to your system and a plan for implementing changes. You will receive a package designed to facilitate a change of practice regarding the use of KCl in your organization.
Presentations to date have been very well received and all attending hospitals are now in the process of removing concentrated potassium chloride injection from patient care areas.
If you have not taken action to remove concentrated potassium chloride vials or ampoules from your nursing units, we would be pleased to support you in making this change. We may be able to visit and present to staff at your organization or will provide telephone and email consultation.
Please contact: Marg Colquhoun at (905) 472-7569 or e-mail at mcolquho@msh.on.ca OR David U at 416 480 4099 or davidu@ismp-canada.org.