1. Cohen, Michael R. RPH, MS, ScD

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A nurse intending to administer potassium chloride injection I.V. to a postoperative patient mistakenly connected the minibag (20 mEq/50 mL) to a Y-site port on the patient's epidural line. After the contents infused over 2 hours, she disconnected the bag. A short while later, an anesthesiologist removed the epidural line. When the nurse returned to infuse another minibag of potassium chloride, she realized that she'd made an error with the prior infusion and notified the anesthesiologist and surgeon. The patient didn't develop any adverse reactions during or after the infusion.


An error analysis showed these breaches in standard procedures:


* In the postanesthesia unit, the nurses typically attached epidural tubing without an access port, but this patient had surgery on a weekend and recovered in ICU. His epidural catheter started leaking and was capped before he was transferred to a medical/surgical unit.


* When the patient complained of pain, nurses in the medical/surgical unit, who'd never before received a patient with a capped epidural catheter and didn't have epidural supplies in the unit, used regular tubing to connect the epidural analgesia.


* The hospital's double-check policy for I.V. potassium infusions had been implemented just a few weeks earlier, and some nurses weren't familiar with all the details, such as the need to double-check pump settings and trace the tubing to the infusion site. Most of the nurses thought that two of them were to simply double-check the medication label and the dose against the patient's MAR.



All staff must receive proper education on a facility's policies and procedures. And any line that's not in use should be removed. If you ever have a question about epidural catheters, call the anesthesia department.