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Occasional Advisor
Posts: 7
Registered: ‎06-02-2010

Re: Joint Commission Medication Storage Webinar

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! Smiley Happy


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

June 2010 


Patient Care Areas

Floor Stock

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";7(2).pdf


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,


Jeanetta Mastron