Potassium overdose using an oral solution: Potassium element expressed in grams as a packaging flaw contributing to...

Area of Science:

• Pharmaceutical Sciences
• Patient Safety
• Medication Error Research

Background:

• Drug packaging design significantly impacts patient safety and treatment outcomes.
• Inadequate packaging can lead to medication misuse, with potentially severe health consequences.

Purpose of the Study:

• To report a specific medication error involving a potassium double dose.
• To identify the packaging flaw that triggered the error.
• To propose a standardization solution to prevent future errors.

Main Methods:

• Case report of a potassium double dose medication error.
• Analysis of drug packaging design and dosage indication.
• Review of medication error causes related to packaging.

Main Results:

• A potassium double dose error occurred due to a packaging flaw.
• The flaw involved the dual expression of dosage (potassium salt and elemental potassium).
• This ambiguity in dosage units on the packaging was the primary trigger.

Conclusions:

• Packaging design is critical for safe medication use.
• Standardizing dosage units to millimoles (mmol) for both packaging and prescriptions can mitigate confusion.
• Implementing millimole standardization is a viable strategy to prevent medication errors like potassium double dosing.