POTASSIUM AND CALCIUM ELECTROLYTE POWDER PACKETS

Description of Event or Problem

AN EVENT OCCURRED RELATED TO HEMODIALYSIS TREATMENT OF THE INCORRECT PATIENT IN AN INPATIENT FACILITY. THE 5 RIGHTS WERE NOT VERIFIED BY THE DIALYSIS NURSE OR BEDSIDE NURSE PRIOR TO INITIATING TREATMENT. THESE EVENTS LED TO THE WRONG PATIENT RECEIVING DIALYSIS FOR APPROXIMATELY 10 MINUTES AND THE PATIENT WHO NEEDED THE TREATMENT EMERGENTLY HAD A DELAY IN CARE. IN ADDITION, THE DIALYSIS ACID BATHING SOLUTION ARE HAND MIXED BASED OFF OF THE PRESCRIBER'S ORDERS. THIS COULD MEAN THE DIALYSIS NURSE IS ADDING MULTIPLE PACKETS OF POTASSIUM AND CALCIUM TO THE ACID BATHING SOLUTIONS WITHOUT ANY VERIFICATION THE CORRECT AMOUNT WAS ADDED. THE ABILITY TO SCAN THE DIALYSATE ACID BATH AND ELECTROLYTE ADDITIVES DOES NOT EXIST. THE MANUFACTURER OF THE ELECTROLYTE ADDITIVES ED LAW PHARMACEUTICALS) AND THE BATHING SOLUTIONS (MEDIVATORS, INC.) DOES NOT PROVIDE A BARCODE ON THE PRODUCTS TO FACILITATE HIGHER LEVEL RISK REDUCTION STRATEGIES SUCH AS BARCODED MEDICATION ADMINISTRATION REQUIRED BY LAW FOR ALL OTHER MEDICATION ADMINISTRATIONS IN INPATIENT HEALTHCARE FACILITIES. REPORT REFERENCE #MW5147611.