After infusing a bag of liquid, why does a hypokalemia patient become hyperkalemia?

In clinical practice, we will encounter all kinds of trivial things.
Some can let us learn knowledge, but some will make us forget.
Remember that a senior nursing staff said that the probability of no error is 1%.
It is 100%, so we should pay more attention to the small things around us.
Perhaps the small things that seem to be trivial will cause irreparable mistakes.

Case review

The patient, female, 80 years old, was admitted to the hospital due to weakness of the limbs.
Upon admission, an urgent blood biochemical test showed that serum potassium was 2.
5mmol/L.
So the doctor gave a slow intravenous infusion of 5% glucose injection 500ml + potassium chloride injection 15ml, after the end of the intravenous infusion After an urgent investigation of electrolytes, the patient's serum potassium actually reached 5.
9mmol/L.
Seeing this result, the tube bed doctor was shocked and suspected that his initial diagnosis was wrong
.

After the incident, Xiao Zhao and the head nurse frank everything and conducted a deep review at the department meeting.
The head nurse also analyzed and improved such incidents in the department to avoid such incidents
.

Cause Analysis

1.
Infusion testing and blood sampling was the main reason for this incident

2.
Nurses lack the spirit of being cautious and have insufficient knowledge of clinical expertise

3.
Nurses are not serious about their work

4.
Lack of communication when working with doctors

Countermeasures

1.
Cultivate the nurse's spirit of being self-conscious

The root cause of this incident is that Xiao Zhao was not serious about his work.
Because of one of his own mistakes, he almost caused an irreversible error.
In clinical work, nurses should pay attention to perfecting themselves, strengthen their sense of responsibility, and cultivate self-consciousness, especially When you are on duty independently, you must always put the interests of the patients first, have a good spirit of being cautious, be honest and calm at work, learn to care for and respect patients, and caring for patients requires not only nurses with superb professional skills, but also High sense of responsibility
.

2.
Good nurse training

Xiao Zhao is a nurse who has been admitted to the department for less than a year and lacks clinical experience, especially for some basic operations.
In order to ensure the safety of clinical nursing, the head nurse should strengthen the training of the department, whether it is clinical knowledge or operational skills.
Be sure to be in the hands of everyone
.

3.
Do a good job in clinical teaching

After entering the department, new nurses should be taught one-on-one by old nurses at the nurse level.
Newborn calves are not afraid of tigers.
Therefore, teachers should often knock on the side and teach with heart.
When new nurses make mistakes, don’t scold them and use gentle ones.
Tell them the mistakes they have made in a tone of voice to avoid making them again.
Teachers should also tell new nurses frequently about some previous adverse events, so that they can understand and know them well
.

4.
In-depth review of the parties involved in the incident

It’s not terrible to happen.
The terrible thing is that you don’t recognize your mistakes.
Although Xiao Zhao made a mistake in this incident, she dared to admit it and made a deep review.
Such incidents also made us vigilant.
To prevent us from doing it again next time

I remember a teacher said before: There are only two types of people in the world who don’t make mistakes, one is a newborn baby, and the other is an elderly person who has passed away, so it is not terrible to say that it is not terrible to make a mistake
.