lert the physician to such things as previous adverse reactions to a medication, other medications the patient is currently taking which may interact with the drug being prescribed, and can alert a physician to dosage errors. It has been estimated that up to 85 percent of medication errors and half of all medication injuries could be prevented by the use of computers (Cowley, 1995).
Nurse-administering errors occur for a number of reasons, including fatigue from working long hours, memory lapses, look-alike packaging and sound-alike names of medications (Cowley, 1995). A review of 10 incidents of patient death resulting from misadministration of potassium chloride showed that eight were the result of direct infusion of concentrated potassium chloride according to the Sentinel Event Alert, (1998). In six of the eight cases, potassium chloride was mistaken for some other medication, primarily due to similarities in packaging and labeling. The most frequent problem was mistaking potassium chloride for sodium chloride, heparin or furosemide. Another contributing factor was the availability of concentrated potassium chloride on the nursing unit.
Potassium chloride for injection concentrate, in vials of
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