Le potassium injectable concentré, emblématique de l’insécurité médicamenteuse des hôpitaux français

Abstract

Despite its proven dangers, the ward stock drug distribution system predominates in French hospitals. This system allows 12 million injectable ampoules of concentrated potassium chloride to circulate uncontrolled each year. Such a situation is absurd for the following reasons : 1) injected by mistake, concentrated potassium kills within seconds ; 2) the true incidence of potassium-related fatalities and incidents is unknown ; 3) fatal intravenous injection of potassium produces no specific anatomical changes and subtle, if any, findings at autopsy ; 4) it is used for capital punishment by lethal injection in various countries ; and 5) healthcare worker serial killers benefit from the fact that potassium is not identifiable in post-mortem examinations and that investigations to find the murderer are complex and of uncertain outcome. Other medications classed as high-risk have similar characteristics to those of concentrated potassium solutions. Injectable potassium can therefore be regarded as emblematic of the lack of safety of the drug use process in French hospitals. The priority measure to protect patients from this deadly risk is to remove these drugs from uncontrolled ward stocks and to provide premixed potassium solutions. Evidence of the increased safety of the unit dose drug dispensing system should compel health policy makers to systematically implement it, thus bringing the drug use process into compliance with existing French and European regulations.