06-14-2010 07:45 PM
Thank you again Dr. Rich for your time and response.
I tried to email you privately but the site does not have you set up for that. I certainly understand why!
I found something that perhaps I need clarification on that supports what I believed was the removal of KCl from the crash carts and hope you can comment or explain it to me as per your discussion even though it appears to be a quote from TJC:
Produced by ECRI Institute
and ISMP under contract
to the Pennsylvania
Patient Safety Authority
Vol. 7, No. 2
Patient Care Areas
While the primary storage of drug products is in the
pharmacy or central supply department, there are a
number of items that are stored in patient care areas
(e.g., medical/surgical unit, emergency department
[ED]). Typically, these are frequently used drugs, such
as hydration solutions. Other drugs (e.g., opiates) may
also be stored in patient care areas in locked cabinets
or ADCs. However, facilities should evaluate what
other drug products are often stored as part of floor
stock. For example, high-alert medications (e.g., concentrated
electrolytes, labetalol injection), especially
those that require intravenous (IV) admixing or compounding,
should not be stored in patient care areas,
as these can cause serious harm when used in error.
The classic example of error-prone floor stock storage
of a drug involved concentrated potassium chloride
vials. In the 1980s and 1990s, many patients were
seriously harmed, and a number of them died, as
a result of errors that occurred when concentrated
potassium chloride vials were stored in patient care
areas.6-9 Sometimes the errors in these cases were due
to knowledge deficits about the dangers of rapid IV
administration of concentrated potassium or, more
often, were mental slips or wrong drug selection
when choosing a vial of medication. Patient safety
organizations called for the removal of concentrated
potassium chloride vials from patient care areas, and
in 2002, the Joint Commission published a National
Patient Safety Goal (NPSG) mandating accredited
hospitals follow suit. Limiting access to this drug has
reduced fatal errors.10,11"
I also work/teach with an acquisition technician who works for the county of LA ( CA) hospital in which they not only took out the vials of [C] KCl but also the pre-diluted LVP's that were once kept in the bottom of the crash carts. They have also removed the premixed pre-diluted LVP's with KCl (one's with red writing on them) from the floor stock in the RN stations not just the crash carts.
So I am wondering about this is there a conflict between not having them in the pt care area and the crash cart?
Can you add to what you have written that perhaps may clarify this? Perhaps I am seeing something incongruent that is not.
Thank you in advance for your time, expertise and kindness,