KCL error - 10 meq vs 20 meq bags

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Mon, 02/02/2026 - 19:22
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camille kamboj
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KCL error - 10 meq vs 20 meq bags

Hello,
we had an error where the RN administered 6 bags of 20 meq KCL in succession because they thought it was a 10 meq bags.

i am curious if any hospital has had any operational or IT rule processes to prevent confusion on 20 meq and 10 meq bags or detect unusual number of 20 meq KCL bags administered so closely.

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