A recent recall of mislabeled commercial IV potassium chloride bags is sparking discussion about best practices for IV electrolyte safety.
We know that IV electrolytes are reserved for patients who have very low electrolyte levels or can’t take po meds. But phosphate, potassium, and magnesium are high-risk meds that can cause harm if used incorrectly.
Review strategies to optimize electrolyte piggyback safety.
Differentiate salt forms. Calcium comes in gluconate or chloride formulations...and their dosing generally has a 3-fold difference.
On the other hand, phosphate comes in sodium or potassium salts...and dosing based on mmol of phosphate is the same.
Look closely at salt forms on vial labels when checking IV-room dispenses...and confirm using barcode-scanning technology, if available.
Store undiluted vials in the pharmacy. Most electrolytes require dilution before admin. For example, undiluted IV potassium or phosphate can be deadly.
Be aware, magnesium and calcium vials are exceptions. They can be stocked in crash carts to use during cardiac emergencies...and magnesium is used intramuscularly in obstetric units to stop eclamptic seizures.
Implement safeguards for these exceptions...locked-lidded dispensing cabinet bins, warning labels, etc...to prevent incorrect use.
Pay attention to IV access. Outside of emergencies, high potassium concentrations (20 mEq/100 mL, etc) and undiluted calcium chloride require a central line...due to hyperosmolarity and vein damage.
Add default text...such as “For central lines only”...to e-Rx order titles AND instructions to avoid admin mix-ups.
Watch rates and durations. Electrolyte piggybacks generally need to infuse over at least 30 to 60 minutes to prevent adverse effects (vein irritation, arrhythmias, etc).
Similarly, double-check order durations to ensure there is a limit...1 or 2 doses, etc...to prevent overcorrecting electrolytes.
Configure electrolyte e-Rxs to have a limited set of approved infusion time and duration options...free-text options should be avoided.
Require all electrolyte piggybacks to be given via infusion pumps...and regularly review and update pump-timing guardrails with IT.
Use premix bags to reduce errors. Making IV piggybacks from scratch increases the risk for compounding errors.
Premix bags are marketed for calcium gluconate...potassium phosphate...potassium chloride...and magnesium sulfate.
Ideally standardize to 1 product size for your EHR and pump system. For example, calcium gluconate 2 gram bags come in 50 mL and 100 mL.
Be ready for meds that impact electrolytes and lead to piggyback replacements using our chart, Lab Monitoring for Common Medications.
- ISMP Canada. Preventable Tragedies: Two Pediatric Deaths Due to Intravenous Administration of Concentrated Electrolytes. https://ismpcanada.ca/bulletin/preventable-tragedies-two-pediatric-deaths-due-to-intravenous-administration-of-concentrated-electrolytes/ (Accessed February 28, 2025).
- ISMP. Targeted Medication Safety Best Practices for Hospitals 2024-2025. https://online.ecri.org/hubfs/ISMP/Resources/ISMP_TargetedMedicationSafetyBestPractices_Hospitals.pdf (Accessed February 28, 2025).
- ISMP. Guidelines for the Safe Use of Automated Dispensing Cabinets. https://www.ismp.org/system/files/resources/2019-11/ISMP170-ADC%20Guideline-020719_final.pdf (Accessed February 28, 2025).
- ISMP. List of High-Alert Medications in Acute Care Settings. https://www.ismp.org/sites/default/files/attachments/2024-01/20240111.pdf (Accessed February 28, 2025).