During two months starting in November 2010, more than 200 patients at seven hospitals in the MedStar Health system in the Maryland and Washington, D.C., region received double their prescribed concentration of potassium acetate.
In response to a shortage of the usual stock dose of the drug (2 mEq/mL), MedStar acted to fill the gap by procuring vials containing a 4-mEq/mL solution. The wrong concentration was entered into the IV compounder software, which then identified the new vials as containing the lower dose, and the drug was administered to patients receiving total parenteral nutrition. No patients experienced injuries or medical abnormalities, which is one reason why the mistake went undetected for so long.
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