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Table 1 Possible failure modes associated with ready-to-use diluted IV KCl solutions

From: Introducing a change in hospital policy using FMEA methodology as a tool to reduce patient hazards

No Failure mode Cause of failure Effect of failure
1 Error in recorded doctor’s instructions: dose or dosing rate Inflexibility of the medical staff in adopting new practices Error in KCL administration due to dose or rate miscalculation
2 Errors in doctor’s instructions documented in medical record: dose or dosing rate Medical staff fixation on familiar pattern of dosage regimen Administration of wrong KCL dose
3 Lack of knowledge regarding new and unfamiliar solutions. Availability of various new and unfamiliar solutions. Erroneous administration of unsuitable solution.
4 The available new diluted KCL solutions do not meet the patient’s needs and characteristics KCL solution choice is not one of the 3-standard concentration options Administration of KCL dose that is unsuitable for the patient
5 The solution vehicle is inappropriate. The infusion itself is incorrect for the patient Availability of only 2 standard solution vehicles. Administration of KCL solution that is inappropriate for the patient.
6 The infusion itself is inappropriate for the patient Lack of ready-to-use KCL solutions in saline 0.45 Administration of KCL solution that is inappropriate for the patient
7 The solution vehicle is inappropriate. The infusion solution itself is inappropriate for the clinical condition of the patient Ready-to-use dextrose-based solutions may aggravate hyperglycemia in patients on regular diets Risk of hyperglycemia.
8 The solution vehicle is inappropriate. The infusion solution itself is inappropriate for the patients clinical condition The new solution may be contraindicated in certain medical conditions May cause hypernatremia, elevated blood volume, elevated blood pressure and pulmonary edema in patients with fluid restrictions such as those with cardiac and renal insufficiency
9 The solution vehicle is inappropriate. The infusion solution itself is inappropriate for the clinical condition of the patient Not every solution is appropriate for correction of severe clinical conditions (i.e., treatment of acute severe hypokalemia) The patient’s emergency status is corrected too slowly
10 Staff is unfamiliar with storage instructions of new solutions Choice of a broad variety of solutions stored Solution administration error: administration of a solution without, instead of with, KCL, and vice versa
11 Staff is unfamiliar with storage instructions of new solutions KCL solutions must be stored separately from non-KCL solutions Delay in administering the required treatment
12 Lack of knowledge regarding new and unfamiliar solutions Lack of special handling instructions Delay in identifying clinical deterioration.
13 Lack of uniform policy regarding administration and frequency of treatment Lack of policy for use of new solutions Variation between the various departments in the quality of treatment