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P 009
  1. H Weerdenburg,
  2. S Jarvis
  1. University Hospital Bristol NHS Foundation Trust


Aim Patients on the Paediatric Intensive Care Unit (PICU) sometimes require intravenous potassium concentrated infusions (20 mmol in 40 mLs of 0.9% sodium chloride) known as ‘High K’ to correct low serum potassium levels. Since the release of the National Patient Safety Alert for intravenous potassium in 2002 a Potassium Supplementation Standing Order (PSSO) has been designed for PICU in order to ensure the safe administration of ‘High K’. The PSSO provides guidance on the appropriate rates and monitoring required while the infusion is running. The aim of the audit is to determine if this is being followed correctly, to ensure that potassium is being administered safely on PICU.

Method Data was collected from PICU patients receiving ‘High K’ using a data sheet designed for the audit. Data was collected on occasions covering 24 hour period from charts, prescribed care booklets and medical notes between November 2012 and January 2013 and was analysed using Microsoft Excel.

Results During the 3 months:

– 18 PICU patients were administered ‘High K’.

– 51/55 (93%) booklets had the PSSO signed and used for 4 days or less (Target 100%).

– 4/18 (22%) patients had cardiac conditions and received ‘High K’ using the PSSO to prescribe the infusion. 14/18 (78%) patients had underlying conditions not mentioned on the PSSO.

– 31/44 (70%) occasions potassium levels were measured correctly within one hour of ‘High K’ being initiated (Target 100%).

– 28/61 (46%) occasions that ‘High K’ continuing the levels were recorded correctly every two hours while the infusion was run (Target 100%).

– 28/55 (51%) of the ‘High K’ rates recorded matched the PSSO instructions according to the patient's current potassium level (Target 100%).

– 48/55 (87%) occasions requirements for ‘High K’ were in line with the PSSO (Target 100%).

– 7/55 (13%) occasions the potassium level greater than permitted in the PSSO (Target 0%).

Conclusion Maladministration of the intravenous potassium containing solutions resulting in death or severe harm is classified in the health care setting as a ‘never event’ according to the Department of Health. No patient on PICU required treatment for hyperkalaemia as a result of administration of ‘High K’ but the standing order was open to several interpretations therefore may have been used inappropriately for 78% of patients. The review of the data collected for the PSSO audit determined that the order was not always followed correctly particularly when recording potassium levels and rates of administration of ‘High K’. A review of the results demonstrates the need for alterations to the standing order to ensure clarification of its role in prescribing of intravenous potassium and of the groups of patients that it applies to. A multi-disciplinary review of the chart is being undertaken.

  • Neonatology
  • Pharmacology

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