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 |