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Twice a week, an 81-year-old man who had end-stage renal disease came to a hospital to receive peritoneal dialysis. The dialysate solution was instilled, allowed to remain in his peritoneum for an hour, then was drained out.
While draining the solution after one of the treatments, the nurse noticed that a number of fibrin clots were blocking the drainage tubing. The standard procedure for this situation was to irrigate the tubing with a 20-ml bolus of a solution composed of 19 ml of sodium chloride and 1 ml of 1,000 units of heparin.
The nurse went to the medication room to prepare the bolus. Arranged on one shelf were all the additives needed for dialysate solutions, including 20 mEq/10 ml potassium chloride injection, 0.9% sodium chloride injection, and 1,000 units/ml heparin solution. She took some vials, prepared the bolus, and injected it into the patient's peritoneal catheter.
The patient immediately clutched his abdomen and cried out in pain. Startled, the nurse realized instantly that she'd used potassium chloride, which is extremely irritating to soft tissue.
She quickly called the patient's doctor, who ordered two rapid exchanges of dialysate to flush the peritoneal cavity. The patient didn't develop transient hyperkalemia or any other effect. But he did suffer intense pain for several minutes.
This error occurred because the nurse was so used to adding potassium chloride to dialysate solutions that she'd automatically reached for it when preparing the bolus. She didn't check the vial's label against a standing order.
The lesson: Don't perform routine procedures routinely. Check medication labels against standing orders. You may prevent a grievous error.