Ensure Safety With IV Potassium Chloride 500 mEq Bags

You’ll need to prevent deadly errors with the new bulk concentrated potassium chloride... 2 mEq/mL in 250 mL (500 mEq) BAGS.

We know concentrated potassium chloride for injection is high-alert. Giving the 2 mEq/mL solution UNdiluted can stop the heart.

That’s why potassium chloride 2 mEq/mL vials and bottles are only for compounding...and should not leave the pharmacy.

It’s also why we only dispense diluted injectable potassium chloride...such as 20 mEq/100 mL (0.2 mEq/mL) IV piggybacks.

Now bulk concentrated potassium chloride will come in 250 mL bags instead of 250 mL glass bottles. The bags may be more prone to mix-ups with IVs meant for direct administration to patients.

In one case, bulk concentrated potassium chloride was confused for D5W and used to dilute heparin...leading to 3 infant deaths.

Safety groups have urged pharmacies to ramp up error-prevention strategies as these bags start to hit pharmacy shelves.

Expect concentrated potassium chloride 250 mL bags to have black port covers to signify dilution is required...like the black closures on concentrated potassium chloride bottles and vials.

Place bold warning labels that say “For pharmacy use only” on BOTH sides of the OVERWRAP of each bag when you receive them.

And when you remove the overwrap, place the same labels on BOTH sides of each BAG.

Store these bags as you would other concentrated electrolytes...separate from other meds.

Use barcode scanning to prevent mix-ups between bulk concentrated potassium chloride bags and other IV bags.

Verify that pharmacy is the only department ordering these concentrated potassium chloride bags. If you get them from central supply or another location, alert your admin ASAP.

Get our Comparison of Potassium Salts resource to see how products stack up.

Key References

  • ISMP Med Safety Alert! Acute Care 2022;27(14):1-4; AA1-AA4
  • ISMP Med Safety Alert! Acute Care 2022;27(15):1-5
Hospital Pharmacy Technician's Letter. September 2022, No. 380922



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