Potassium salts are administered intravenously to address hypokalaemia in patients who cannot receive the electrolyte orally or when rapid replacement is required.

Potassium incidents

Incidents involving administration of intravenous potassium can result in fatal patient outcomes. Adverse incidents related to intravenous potassium use can include:

  • Too rapid intravenous infusion of a potassium chloride infusion related to failure to use a rate limiting device such as an infusion pump, or incorrectly programing an infusion pump
  • Administration of a bolus of concentrated potassium chloride (for example, potassium chloride 10 mmol in 10 mL) as a result of a selection error. For example, mistakenly selecting a potassium chloride ampoule instead of a sodium chloride 0.9% ampoule when preparing an intravenous flush
  • Failure to adequately mix a potassium chloride concentrate that has been added to an infusion prior to administration can result in the patient receiving a bolus of concentrated potassium chloride solution.

Potassium Standard

The Potassium (Intravenous) Standard of the NSW Health High-Risk Medicines Management Policy (PD2020_045) outlines the minimum actions required to reduce risks associated with intravenous potassium. The Potassium Standard includes a risk mitigation strategy and addresses intravenous potassium prescribing, storage, supply, administration and patient information and education.

The tool below can also be used to assist hospitals in monitoring risks associated with intravenous potassium. It can also be used to monitor local implementation and compliance with the Potassium (Intravenous) Standard of the High-Risk Medicines Management Policy Directive.