Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
A real time integrated electronic Medical Record (ieMR) alert preventing unsafe IV potassium infusion rates by checking orders against safe limits and prompting prescriber action.
Dates: August 2025 - August 2025
Implementation sites: Queensland statewide
Partnerships: DHS, OCCIO, Children's Health Queensland
Aim
To reduce harm from intravenous potassium chloride through automated, real time clinical decision support that identifies unsafe infusion rates at the point of prescribing.
Outcomes
- Clinical safety impact: The alert has fired 14 times in two weeks, prompting clinicians to modify or cancel unsafe orders before administration.
- Projected harm prevention potential: Early usage suggests each alert represents interception of a potentially unsafe infusion, approximately one potential life saving intervention per day.
- Alignment
with national safety standards: Supports APINCHS high risk medicine requirements and national alerts for concentrated IV potassium. - Adoption and usability: The alert fires for prescribers across the statewide ieMR, which includes 75,194 users, of whom 15,871 are physicians, working across 89 QH facilities and caring for Z patients. Its placement at order sign off and its clear action prompts (Cancel / Modify / Override) support consistent uptake.
Background
Intravenous potassium chloride (KCl) is classified as a high risk medicine by the Australian Commission on Safety and Quality in Health Care under the APINCHS framework due to its narrow therapeutic index and the risk of fatal outcomes when administered incorrectly. Multiple national alerts emphasise the dangers of excessive or incorrect IV potassium administration and recommend strong system safeguards. Despite these measures, a significant safety gap persisted in the statewide ieMR: no decision support existed to alert prescribers when infusion rates exceeded clinically safe thresholds.
Near miss incidents across Children’s Health Queensland and Metro South Health and Hospital Services demonstrated that orders could be placed above recommended limits without any system intervention. A technical investigation confirmed that standard dose range checking was not possible, as mmol based rate calculations were incompatible across different concentrated potassium formulations. This required the creation of a customised discern alert capable of assessing product specific concentration, age-based dosing, and weight based paediatric calculations. The combination of near miss incidents, national high risk medicine guidance, and the lack of an automated safeguard established a compelling need for this project.
Methods
Digital Health Solutions (DHS) in collaboration with Children’s Health Queensland and OCCIO designed a custom real time discern alert for concentrated potassium chloride orders, firing at order sign off when rates exceed safe limits:
- Adults: >20 mmol/hr
- Paediatrics: >0.3 mmol/kg/hr (capped at 20 mmol/hr)
The alert evaluates:
- Product type
- Patient age
- Recorded weight
- Calculated infusion rate
If unsafe, the alert interrupts workflow and displays:
- Clear risk information
- Required clinical actions (check calculations, consider cumulative potassium, consult guidelines)
- Order details for rapid correction
- Options: Cancel, Override, or Modify (default)
The solution was developed using human centred design principles to reduce cognitive load and prevent alert fatigue.
The project underwent governance review and approval through statewide pathways include the Clinical Decision Support Working Group (CDSWG) and the Medication Sub Specialty Group (MedsSSG).
Discussion
Success factors included clear clinical thresholds, a custom technical solution overcoming limitations of standard dose checking, and strong clinician engagement in designing comprehensible alert wording.
Limitations include inability to calculate cumulative potassium exposure across multiple concurrent sources, reliance on correct weight documentation for paediatric calculations, and dependency on maintaining product synonym mappings as formulations evolve.
Despite these, the alert delivers significant value by shifting safety checks upstream, complementing national safety recommendations that emphasise preventing incorrect IV potassium administration before it occurs. Early data demonstrates a meaningful reduction in prescribing stage risk.
Scalability: Given its integration into the statewide ieMR, this solution has be consistently deployed across all participating facilities. Future enhancements could include cumulative potassium logic, mandatory monitoring prompts, and expanded coverage for additional high risk electrolytes.
The project demonstrates strong alignment with Queensland Health's digital safety objectives and the national expectations for safeguarding high risk medicines.
References
https://www.safetyandquality.gov.au/our-work/medicines-safety-and-quality/high-risk-medicines/high-risk-medicines-resources
https://www.safetyandquality.gov.au/sites/default/files/2021-08/high-risk-medication-alert-intravenous-potassium-chloride-2003.pdf
Key contact
Sarah Lourens
Application Manager
Medications
eHealth Queensland