• A J Lankshear, T A Sheldon, K V Lowson, I S Watt, and J Wright.
• Department of Health Sciences, University of York, UK. al25@york.ac.uk
• Qual Saf Health Care. 2005 Jun 1; 14 (3): 196-201.

ObjectivesTo assess the effectiveness of the response of NHS hospital trusts to an alert issued by the National Patient Safety Agency designed to limit the availability of concentrated potassium chloride in hospitals in England and Wales, and to determine the nature of any unintended consequences.DesignMulti-method study involving interviews and a physical inspection of clinical areas.Setting207 clinical areas in 20 randomly selected acute NHS trusts in England and Wales between 31 October 2002 and 31 January 2003.ParticipantsSenior managers and ward based medical and nursing staff.Main Outcome MeasuresDegree of staff awareness of and compliance with the requirements of the national alert, withdrawal of concentrated potassium chloride solutions from non-critical areas, provision of pre-diluted alternatives, storage and recording in accordance with controlled drug legislation.ResultsAll trusts required that potassium chloride concentrate be stored in a separate locked cup-board from common injectable diluents (100% compliance). Unauthorized stocks of potassium chloride were found in five clinical areas not authorized by the trust (98% compliance). All trusts required documentation control of potassium chloride concentrate in clinical areas, but errors were recorded in 20 of the 207 clinical areas visited (90% compliance). Of those interviewed, 78% of nurses and 30% of junior doctors were aware of the alert.ConclusionsThe NPSA alert was effective and resulted in rapid development and implementation of local policies to reduce the availability of concentrated potassium chloride solutions. The success is likely to be partly due to the nature of the proposed changes and it cannot be assumed that future alerts will be equally effective. Continued vigilance will be necessary to help sustain the changes.

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