The following post was written by Karen Yakabosky, Pharm D, a Clinical Specialist in Pediatrics Pharmacy at Reading Health System.

 Her experience led directly to the development of the NICU Emergency Medication Calculator for RxTOOLKIT. It has proved to be an invaluable patient safety tool now in use at her organization.

 Near Miss:

I uncovered an issue in our NICU with continuous Dextrose + Electrolyte solutions. The easiest way to explain it is to provide a real example.

Our hospital policy is to limit potassium chloride concentrations in NICU:

  • Peripheral line: Do not exceed KCL 40 mEq / Liter (0.04 mEq / mL)
  • Central line: Do not exceed KCl 80 mEq / Liter (0.08 mEq / mL)

Physician Order

  • Baby Weight was 3.958 kg
  • Via Peripheral line
  • Potassium Chloride dose was 2 mEq / kg / DAY
  • Infusion was ordered at 100 mL / kg / DAY

This calculates out to:

Volume of IV = 396 mL (3.958 kg x 100 mL / kg)

Potassium Chloride = 7.9 mEq (3.958 kg x 2 mEq / kg)

Concentration = 7.9 mEq / 396 mL (0.02 mEq / mL)

Order Change

The next day the physician decided that the only change needed was to decrease the volume to be infused.

The physician entered the electronic medical record (EMR) and modified the current order by simply changing the infusion volume from 100 mL/kg/day (396 mL) to 25 mL / kg / day (99 mL).

While this change appears to be simple; it can result in an unacceptable concentration of electrolytes. If the EMR is not automatically calculating each individual electrolyte concentration AND warning when a specific guideline is exceeded, an unacceptable concentration can be ordered, dispensed and administered. This is especially true if a new bag  is accidentally prepared and dispensed. While the intent of the physician may have been to adjust the volume to be infused by tapering the infusion rate, this is NOT the only change that was occurring. The dose of electrolytes was not adjusted in proportion with the volume to be infused. There might be no warning and an unacceptable concentration parameter can be exceeded.

In this instance…

This new order calculates to:

Volume of IV = 99 mL (3.958 kg x 25 mL / kg)

Potassium Chloride = 7.9 mEq (3.958 kg x 2 mEq / kg)

Concentration = 7.9 mEq / 99 mL (0.0797 mEq / mL)

Not only is that concentration unacceptable for peripheral line administration, it almost exceeds the concentration for central line.


This change can go un-detected in many electronic medical record systems (EMR). One option to consider is to not allow physicians to edit existing orders. This decision can result in some push back by physicians looking to be more efficient. This potential problem can result if an order is changed as part of a decision to taper fluids and a new bag is ordered. There are several ways that this process can compromise patient safety.

I helped to design a computer application with that does the systematic concentration check for us. On several occasions now, this application has detected situations where the concentration parameters have been exceeded and warned us. In each instance, we were able to alert the physician and have the order changed appropriately.


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