The Institute for Safe Medication Practices on May 17 issued an alert warning pharmacists of the risk of errors with a new presentation of potassium chloride concentrate from B. Braun.
The company recently transitioned from packaging the concentrate in glass vials to plastic bags.
ISMP said several pharmacists and pharmacy technicians have expressed concerns about the potential risk of mixing up the concentrate with other intravenous infusion bags, as the new packaging features similar labeling to other IV products.
"The potassium chloride for injection in the bag is highly concentrated and can stop a patient’s heart if accidentally administered undiluted, resulting in a fatal outcome," ISMP said.
Healthcare facilities that opt to use this product should take measures to prevent potentially fatal medication errors, the group said. Such actions include immediately placing warning labels on the product once unpackaged from its box and allowing only the pharmacy to store and use the product, which is intended to be diluted with IV fluid.
View ISMP's full alert here.