# Situation: The adult medical ward of a tertiary hospital reviews its medication safety events. At 05:45, a nurse preparing a 06:00 flush for a 67-year-old man with heart failure picks up a vial of concentrated potassium chloride instead of sodium chloride 0.9%, which is stored in the next bin. The barcode scanner rejects the vial before any drug is drawn up, and the nurse gives the correct flush. The nurse manager reviews the event. Which change would MOST reliably prevent a recurrence?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: The adult medical ward of a tertiary hospital reviews its medication safety events. At 05:45, a nurse preparing a 06:00 flush for a 67-year-old man with heart failure picks up a vial of concentrated potassium chloride instead of sodium chloride 0.9%, which is stored in the next bin. The barcode scanner rejects the vial before any drug is drawn up, and the nurse gives the correct flush.

The nurse manager reviews the event. Which change would MOST reliably prevent a recurrence?

## 보기

1. Add bright warning labels and move the two bins farther apart
2. Have the pharmacy remove concentrated potassium from ward stock **✔ 정답**
3. Require the nurse involved to repeat medication safety training
4. Remind all staff at the next huddle to read every label three times

**정답: 2**

## 해설

Safety interventions differ in strength: forcing functions and physical design are strongest, followed by automation and standardization, then checklists, labels, and reminders, with education and policy alone weakest. Removing concentrated potassium chloride from ward stock eliminates the hazard, so the same mix-up cannot happen again on the ward. Labels, reminders, and retraining depend on human attention and leave the hazard in place.

## 심화 해설

Core principle: hierarchy of safety interventions
Not every safety measure is equally strong. The most reliable interventions change the system so the error becomes physically impossible, rather than asking a busy clinician to remember one more step. In this event, the barcode scanner already worked as a forcing function by rejecting the wrong vial before any drug was drawn up. However, the scanner is a downstream barrier: the concentrated potassium was still present on the ward, and the nurse still had to pick it up first. The strongest fix is to remove the hazard itself from the unit.

Removing concentrated potassium chloride from ward stock eliminates the possibility of this mix-up at its source. If the vial is not physically available on the ward, no nurse can accidentally select it during a flush, regardless of fatigue, distraction, or look-alike packaging. This is why option 2 is the most reliable change.

Why labels, reminders, and retraining are weaker
Options 1, 3, and 4 all rely on human attention and vigilance. Bright warning labels can fade, be overlooked, or become so familiar that staff stop noticing them. Moving bins farther apart reduces but does not eliminate the chance of reaching into the wrong bin. Retraining one nurse addresses an individual, not the system, and a huddle reminder depends on every staff member recalling the instruction at 05:45 under time pressure. These measures leave the concentrated potassium in place, so the same error remains possible.

Watch out! A common exam trap is choosing an educational or labeling intervention because it feels proactive. In medication safety questions, the strongest answer is usually the one that removes the dangerous product or redesigns the process so the error cannot occur.

Evidence on concentrated potassium removal
Concentrated potassium chloride injected intravenously by mistake can cause cardiac arrest within seconds, and fatal cases often leave little or no specific finding at autopsy [1][2]. Because the consequences are so severe and so rapid, relying on preparation and infusion guidelines alone has not been enough to prevent deaths. Countries that removed concentrated potassium ampoules from ward stocks observed a reduction in accidents [1]. One review notes that the ward stock distribution system allows millions of injectable ampoules of concentrated potassium chloride to circulate uncontrolled each year, which is described as an unacceptable situation given the lethality of an accidental injection [2].

When a high-alert medication is not needed urgently on the ward, keeping it out of routine floor stock is a system-level removal of the hazard. If a patient genuinely requires concentrated potassium, it can be dispensed as a patient-specific, pharmacy-prepared infusion rather than stored as a multi-use vial in a general bin.

Where the barcode scanner fits
Barcode scanning is a valuable automation layer that caught this particular error. However, automation still depends on the hazardous vial being present and on the nurse scanning before drawing up. Surveillance gaps in voluntary reporting mean many medication errors go undetected, so a single near-miss caught by a scanner does not prove the system is safe . The scanner is a backup, not a replacement for removing the concentrated potassium from the ward.

| Intervention | Strength | Why it is weaker or stronger here |
| --- | --- | --- |
| Remove concentrated KCl from ward stock | Strongest | Eliminates the hazard; mix-up becomes impossible |
| Barcode scanner rejection | Strong automation | Catches error but hazard remains on unit |
| Warning labels and bin separation | Moderate | Relies on visual attention; hazard remains |
| Retraining or huddle reminder | Weakest | Depends on memory and compliance; hazard remains |

Key point! In a medication safety question, compare options by asking: “Does this remove the dangerous product or change the process so the error cannot happen?” If yes, it is likely the strongest answer. If it only adds a warning, a reminder, or more education, it is weaker because the hazard is still present [1][2].References (research sources)

- [1][Medication errors with concentrated potassium intravenous solutions: Data of the literature, context and prevention].Research articleCharpiat B, Magdinier C, Leboucher G, Aubrun F (2016) · DOI: 10.1016/j.pharma.2015.07.004

- [2][Not Available].Research articleCharpiat B, Leboucher G, Maire P, Schmitt É (2020) · DOI: 10.3917/rsi.141.0078

## 임상 시나리오

Removing High-Alert Medications from Ward StockStrongest system-level prevention of potassium chloride mix-ups
The most reliable intervention is to eliminate the hazard at its source. If concentrated potassium chloride is not physically present on the ward, the error becomes impossible, regardless of fatigue, distraction, or look-alike packaging.

This follows the hierarchy of safety interventions: forcing functions and physical removal are strongest, followed by automation and standardization, then labels and checklists, with education and policy alone weakest. The barcode scanner worked as a downstream barrier, but the hazardous vial remained available for selection.

CautionConcentrated potassium chloride is a high-alert medication that can cause fatal arrhythmias if given undiluted or in error. Labels, reminders, and retraining leave the vial in place and depend on human attention, so the same mix-up remains possible.

## 핵심 개념

- **Forcing function** — A design feature that makes an error physically impossible or blocks it before completion, such as a barcode scanner rejecting a wrong medication.
- **Hierarchy of safety interventions** — A ranking of safety measures from strongest to weakest: forcing functions and physical design, automation and standardization, checklists and labels, education and policy.
- **Concentrated potassium chloride** — A high-alert medication that can cause fatal cardiac arrhythmias if given undiluted or in error; should be removed from ward stock when possible.
- **Look-alike packaging** — Medication containers that resemble each other visually, increasing the risk of selection errors.
- **System-based intervention** — A change that modifies the environment or process so that human error is less likely or impossible, rather than relying on individual vigilance.

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