Evaluating the Severity of Reported Potassium-Related Errors and Developing Safeguards to Improve Potassium Safety in...

This study aimed to describe high-risk medicine, potassium-related incidents, reported in intensive care units (ICUs) nationally, investigate the consensus of an expert panel's evaluations and the inter-rater reliability between the expert panel and the original data classifiers in evaluating the clinical severity of patient harm, and develop safeguards by the expert panel to improve potassium safety in ICUs.

Potassium-related incidents over an 11-year period were examined retrospectively and a subsample of typical errors that had caused patient harm was selected for error severity evaluation and development of safeguards, employing a prospective modified nominal group technique with an expert panel. The consensus of evaluations was determined using averages and the inter-rater reliability by using Cohen kappa. In addition, an expert panel discussion was conducted to develop recommendations for consensus-based safeguards to improve potassium safety in ICUs.

Of the 440 reported potassium incidents, 34% were related to wrong concentration, and 24% to wrong medication. Twenty-six percent were reported to have caused consequences for patients. The expert panel achieved almost complete consensus on the evaluation of the clinical severity of the subsample of errors (89%, n=42/47). The inter-rater reliability between the expert panel and original data classifiers was low (κ=0.34). The expert panel suggested multilevel safeguards.

Most potassium-related incidents were related to wrong concentration and medication. The consequences of potassium-related errors may be more serious than reported. The quality of harm categorisation needs improvement to provide more reliable information on medication errors to improve medication safety. The expert panel suggested multilevel safeguards to improve potassium safety in ICUs.