Potassium chloride injection still poses threats to patients.

Vol. 36 No. 5 • May 2011 • P&T® 241 of breath, and his physician had prescribed an IV dose of furosemide (Lasix, Sanofi-Aventis). The pharmacy was closed, so a nurse entered the secured section of the pharmacy to obtain the drug. She mistakenly selected a vial of KCl instead of furosemide; both drugs were kept on nearby shelves just above the floor. She took the vial to the unit, withdrew the medication, and administered it to the patient. A mental slip— mistakenly associating “potassium” on the label with the potassium-excreting diuretic—likely resulted in the nurse’s failure to recognize the error until she went back to the pharmacy to document removal of the drug.