A sentinel event wherein a patient dies due to the nurse mistakenly injecting 10 ml Potassium Chloride because it appears similar to normal saline will result in serious consequences. This may include actions by the state board, loss of employment and or licenses, and criminal or civil charges (Anderson, 2010). However, the effects of Potassium Chloride toxicity, which is used in lethal injection, are well known. A dosage that is life sustaining rather than life ending should not exceed 10 meq per hour (“Potassium Chloride, n.d.).

The Joint Commission recognized that concentrated Potassium Chloride mistakes were resulting in patient deaths in the 1990s, and in 2002, the Joint Commission National Patient Safety Goal forced most hospitals to remove Potassium Chloride from its regular floor stock. It is now recommended that the potential for errors due to similar appearing packaging be evaluated in all high-alert medications, access to concentrated Potassium Chloride should be limited, and only premixed solutions should be used (Grissinger, 2011). Potassium Chloride mistakes have resulted in death due to mistaken drugs but also because of errors in mixing the solution.

A nurse may face negligence charges in this case because there are a number of checks in place in all states for the reduction of medication errors. Potassium Chloride has been highlighted in safety discussions because of its known potential for sentinel events. However, the high-alert status of this medication implies that other safeguards either were not required or were not implemented, so there are other parties likely to be implicated in the responsibility of preventing this error. The hospital where this occurred will almost definitely be implicated in the responsibility of putting in proper safeguards in order to avoid this type of medication error. Accredited hospitals must report its sentinel events to the Joint Commission for further research and investigation into improving patient safety.