172-1071 / Practice guidelines and tools for the safe use of intravenous potassium

GOP Information
Organisation sharing the GOP
Related practices from PaSQ database
Ministry of Health, Social Services and Equality (MSSSI) and Institute for Safe Medication Practices-Spain (ISMP-Spain)


Quality management system
Program on quality and safety
Medication / IV Fluids
Patient safety culture / Patient safety climate
GOP Description
Implementation level
Clinical settings
The objective was to promote and facilitate the implementation of safety practices and safeguards to reduce risks to patients derived from the use of intravenous potassium in Spanish hospitals.
The documentation contains “Recommendations for the Safe Use of Intravenous Potassium”, which includes safety practices for all the procedures that accompany the use of intravenous potassium in hospitals (storing, prescribing, preparing, distributing, administering and monitoring). They encompass a total of 18 actions to be performed by the management team of the hospital, the Risk Management Unit, the Pharmacy and Therapeutics Committee, the pharmacy service, and those persons in charge of medical units, doctors, and nurses.
The tools include support material designed to facilitate the dissemination and implementation of the recommendations in hospitals: a protocol model that can be used as a general guideline, easily adapted to each hospital’s unique situation (the protocol establishes safe practices for storing, prescribing, preparing, distributing, administering and monitoring intravenous potassium, standardizes the available presentations, and defines the medical units in which potassium concentrate should be available), a slideshow presentation with accompanying explanations, several models for posters and folded information leaflets, and publications of interest.
Timeframe implementation
For developing and publishing the materials at both national and regional levels: 6- 9 months.
For adapting the protocol and materials and for implementing them at the local level: 6 months.
Implementation tools available
All the materials are posted and available for downloading on the Ministry of Health’s webpage: http://www.seguridaddelpaciente.es/formacion/tutoriales/MSC-CD4/
The Ministry of Health has published a booklet with an accompanying CD-ROM and has sent it out to all Spanish hospitals.
Implementation cost
For development, design, and creation of the recommendations and materials: 40.000 €.
For printing posters and labels individualized for each hospital: between 1000 and 1500 €.
Method used to measure the results
Number of hospitals that implemented the “Recommendations for the Safe Use of Intravenous Potassium”.
The Medication Safety Self-Assessment for Hospitals includes an evaluation item related to the implementation of safety practices for intravenous potassium.
MSSSI safety indicators include information about the implementation of safety practices for high risk medications
We are aware that, at the regional level, some regional health services have been using these materials to implement safety practices in their hospitals.
Results obtained in 2011 from the Medication Safety Self-Assessment for Hospitals show a greater degree of implementation for these practices in Spanish hospitals than was the case in 2007 (33.2% vs. 13.6%).
Analysis of the results
We expected later surveys to show higher degrees of implementation than they actually did.
Implementation barriers
Did you find implementation barriers?
Please describe implementation barriers
At the local level: 1) Initially, one of the barriers that affected implementation was the lack of availability of some presentations of ready-mixed potassium infusion solutions (prefilled bags).
2) In order to implement these practices and safeguards, multidisciplinary collaboration led and/or supported by the hospital management team must be present.
Describe the strategies used to overcome the barriers (If needed)
For #1) Increased pharmaceutical industry production of presentations of potassium infusion solutions.
For #2) Encouragement from the MSSSI through its national patient safety strategy for the implementation of safety practices for high risk medications.
Other information
Other information about the GOP that you would like to add (Link or attached document)
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