Abstract
Objectives: To 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.
Design: Multi-method study involving interviews and a physical inspection of clinical areas.
Setting: 207 clinical areas in 20 randomly selected acute NHS trusts in England and Wales between 31 October 2002 and 31 January 2003.
Participants: Senior managers and ward based medical and nursing staff.
Main outcome measures: Degree 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.
Results: All trusts required that potassium chloride concentrate be stored in a separate locked cupboard from common injectable diluents (100% compliance). Unauthorised stocks of potassium chloride were found in five clinical areas not authorised 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.
Conclusions: The 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.
Full Text
The Full Text of this article is available as a PDF (114.8 KB).
Selected References
These references are in PubMed. This may not be the complete list of references from this article.
- Greenhalgh Trisha, Robert Glenn, Macfarlane Fraser, Bate Paul, Kyriakidou Olivia. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82(4):581–629. doi: 10.1111/j.0887-378X.2004.00325.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Sheldon Trevor A., Cullum Nicky, Dawson Diane, Lankshear Annette, Lowson Karin, Watt Ian, West Peter, Wright Dianne, Wright John. What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews. BMJ. 2004 Oct 30;329(7473):999–999. doi: 10.1136/bmj.329.7473.999. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.