When in Doubt, Clarify

A pharmacy vendor for a long-term care facility received an order for potassium chloride (KCl) solution 10 mEq/15 mL with a dose of 10 mEq once daily. KCl solution is commercially available only in a strength of 20 mEq/15 mL. The pharmacy never clarified the order but instead, sent out the 20 mEq/15 mL solution and labeled the bottle "10 mEq=7.5 mL" which would have yielded the desired dose. During their annual visit, the Department of Public Health noted the disconnect between what was written in the physicians' order section, the medication administration record (MAR), and what the pharmacy sent and labeled.  The good news was the disconnect did not result in patient harm because the correct dose was on the label.  The bad news was the error triggered a further investigation which uncovered a number serious, possibly life-threatening, medication issues.  As a result, the facility received an immediate jeopardy (IJ) citation and a significant fine. The pharmacy vendor, who started the chain of events simply by not clarifying the KCl order, was terminated. When in doubt, clarify!