P34 The intravenous use of strong potassium chloride in paediatric intensive care (PICU)

Aim Incorrect use of strong potassium is listed as a ‘Never Event’, 1 largely preventable patient safety incident if national 2 or healthcare provider guidance followed. Local for the intravenous (IV) available paediatric intensive care, with multiple considerations to follow before it should be considered. This audit investigates IV in Paediatric Intensive Care Unit (PICU) against current PICU specific guidance. The aims being assure and provide direction improve compliance safety. Method Audit standards were adapted from hospital guidelines on PICU. Data points set using these standards, standardised data collection form was piloted finalised. collected during 12 hour window each day over total 20 days. Patients identified through entries section infusion chart. analysed excel. Results Nineteen out 31 patients (61%) had their serum measured within hours administration. requiring increased urine output, 11 (58%) having diuretic therapy review. Nine 28 (32%) been prescribed sparing (PSD), 3 excluded due recent > 4.5 mmol/L. Of not given PSD, reasons included unintentional omission, previously crossed off chart re-prescribed, high output. maintenance fluids parenteral nutrition could have contents optimised. Optimisation content missed only 13 (23%) 9 PN increased. Fifteen (48%) tolerating enteral feeds oral supplements where possible, there no clinical need urgency opt IV. Conclusion Several steps detailed reduce followed greater extent, reducing risks potassium. Relaunching guideline further education required; particular emphasis PSDs, optimising nutrition, reviewing therapy, supplementation. Reminding prescribers that considered prior electing route. Education regarding omission PSD output required. Time savings made by following requires several checks time consuming prepare. Following relaunch re-audit needed measure whether interventions improved reduced unnecessary use. References NHS Improvement. Never Events list 2018 (updated February 2021). London, 2021. Available from: https://www.england.nhs.uk/publication/never-events/ National Patient Safety Alert. ‘Potassium solutions: errors occurring administration.’ NPSA 2002. Rhodes LA, Wall KM, Abernathy SL, et al . Decreasing pediatric cardiac care: quality improvement project. Pediatr Crit Med 2016; 17 :772–8.