Patient Scenario – Iatrogenic Hyperkalemia
William was a 3 month old infant who was hospitalized on the pediatric ward for
treatment of complications following a surgical procedure. During this particular night,
he had been under the care of Dr. Ben D., a bright 1st year surgical resident who had only
started his pediatric surgery rotation two days ago. Since his only prior exposure to
pediatrics was during his 3rd year child health clerkship, he was a bit apprehensive about
the coming month; however, he seemed to have a great team with which to work, and the
nurses on the pediatric floor seemed to go out of their way to assist him.
He had been called with a couple of minor issues regarding the infant William
during the night. Other patient issues and an OR case had kept him awake all night. Just
before he handed off the “on call” beeper to his oncoming colleague at 7AM the next
morning, Judy B., the peds nurse, had called him to report a panic value from the
morning labs – a K+ level of 2.5. Judy was an experienced nurse who was new to the
unit, and had little recent history in caring for children. She suggested that this was low
enough that the child probably needed some IV potassium. The resident recalled that he
had given potassium as an IVPB solution to another (adult) patient the previous week,
and he ordered the same dose of 40 mEq IVPB over four hours.
Judy thought this dose sounded similar to doses she had given in the past, but
asked a co-worker to verify that it sounded OK. The co-worker suggested she “look it
up”; however, she didn’t know of any references on the ward that would allow her to
easily check this. Change of shift was rapidly approaching, so she went ahead and faxed
this order to pharmacy. The order arrived at the same time as many other orders written
by morning rounding teams, so it was placed in a stack of several dozen orders to be
reviewed by the pharmacist. Thirty minutes later, the pharmacist verified the order, and
instructed the ward that the IVPB could be mixed from medications contained in the
Pyxis machine. Although all concentrated electrolytes had been removed from the ward
years ago in accordance with Joint Commission patient safety guidelines, IVPB solutions
were still contained in the Pyxis machine. The night nurse, Judy, hung the solution as she
was handing off care to the oncoming day nurse, Carol.
At 2PM that afternoon, the lab called another alert value to Carol on the ward –
this time it was a high potassium of 7.4! The surgical team was notified of this result and
immediately came to the floor to investigate. The physician saw that the patient had
received the IVPB K+ infusion earlier in the day. The infant was apparently doing well;
however, due to the severity of the hyperkalemia, Kayexalate was administered.
William’s potassium returned to normal by the following day, and suffered no apparent
adverse effects of the brief period of hyperkalemia.
Judy, the surgical resident, Carol, and the pharmacist all expressed that they felt
personally responsible for the error.
Case Contributing Factors:
Equipment (design, availability and maintenance)
Pyxis machine did not alert provider when a large dose of potassium was removed from
the machine.
Environment (staffing levels and skills, workload and shift patterns, administrative
and managerial support, physical plant)
No reference sheets to allow confirmation of correct dose of pediatric medications.
Teamwork (verbal and written communication, supervision and assistance)
Order sheets for pediatric ward did not look different than adult order sheets, so
pharmacist did not initially recognize that order was for an infant.
Staff (knowledge and skills/training, competence, physical and mental health)
Orientation to pediatric intensive care unit was inadequate both for the nurse and the
resident physician. Resident physician was fatigued. Increased work load associated
with the upcoming shift handoff seemed to play a role in inability to adequately
doublecheck order.
Institutional Context (economic and regulatory situation, availability and use of
protocols, availability and accuracy of tests)
No readily available medication protocols for nurses or physicians.
Organization/Management (financial resources and constraints, organizational
structure, policy standards and goals, safety culture and priorities)
No policy for routine double-checking of high risk medications.
Patient (complexity and seriousness of condition, language and communication,
personality and social factors)
Patient was an infant and unable to advocate for self. To what degree were parents
engaged as patient advocates? Were parents at bedside when this occurred?
What can be done to keep it from happening again?
Standardize/Simplify/Make Protocol
Automation/Computerize
Education/Training
Improve or Change Devices/Equipment
Communication
Other (Describe)