How can you avoid this medication error?

See how your staff or students analyze this error--and how they'd avoid it What happened: Jean Watson, a postoperative patient, has a low serum potassium level on her second postoperative day (2.1 mEq/L), and her health care provider orders an additional 20 mEq of KCl to be added to her I.V. bag. Currently, she has 1,000 ml 5% dextrose in 0.45% NaCl with 20 mEq KCl hanging with 200 ml left in the bag and infusing at 125 ml/hour. The nurse draws up the 20 mEq of KCl and adds it to the current infusion without changing the infusion rate. Situation: This could cause hyperkalemia that might be lethal. Adding KCl to an I.V. bag with 200 ml remaining can create a solution too concentrated to administer I.V. What should have been done: The nurse should have discarded the hanging bag, wasting the 200 ml of I.V. fluid, and hung a new 1,000-ml bag with the additional 20 mEq of KCl added. That I.V. would have 40 mEq of KCl per 1,000 ml, which can be safely given at 125 ml/hour. Administering the I.V. solution through an infusion pump would be safest because it avoids a potential sudden infusion of excess I.V. fluid. Source: Clinical Drug Therapy: Rationales for Nursing Practice, 8th ed., AC Abrams, Lippincott Williams & Wilkins, 2006.