Abstract

Injectable solutions are usually presented in a strength which can be given directly to the patient without dilution. However, a few sterile solutions need to be diluted before administration. The most widely used of these is Sterile Potassium Chloride Solution BP (1.5 g [20 mEq] in 10 ml; 15%) which is intended to be diluted and given by slow intravenous infusion; rapid intravenous injection of the undiluted solution can prove fatal. This solution is packed in similar ampoules to Sodium Chloride Injection BP and mistakes have occurred because one has been confused with the other. Although each potassium chloride ampoule is labelled ‘dilute before use’, this instruction has not always proved a sufficient safeguard, especially as the small print on the ampoule can be difficult to read. Ultimately this problem could be minimised by having ready-made infusions incorporating appropriate quantities of potassium.