Misstag med koncentrerade kalium- och natriumlösningar. Analys och lärdomar av anmälda ärenden
Engelsk titel: Incidents involving concentrated potassium and sodium solutions. Analysis and lessons learned from reported cases
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Författare:
Akselsson, Roland
;
Fyhr, Annsofie
Email: annsofie.fyhr@design.lth.se
Språk: Swe
Antal referenser: 20
Dokumenttyp:
Artikel
UI-nummer: 11041157
Sammanfattning
Serious incidents affecting patient safety involving concentrated solutions with potassium (as chloride or phosphate) and sodium chloride reported to Swedish authorities (lex Maria and HSAN), 1996-2009, were investigated to see what can be learnt from them. At least 32 incidents have occurred with serious consequences for patients including fatalities, life-threatening arrhythmias, and skin necrosis. Look-alike packaging was identified as one of the contributory causes. Approximately 30% of the incidents occurred in home care, where nurses’ work often is interrupted, lighting is poor, and drugs are improperly stored. Accessibility to concentrated solutions in healthcare, especially potassium solutions, should be limited. National authorities and the pharmaceutical industry should cooperate for a change in packaging in order to minimise the risk for errors. Experiences from reports like these and other incident analyses should be used locally and also aggregated on a national level for learning and effective action.