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City Fredericton / Toronto / London / References Bugg / / Company Eli Lilly / Sentinel / ISMP Canada Safety Bulletin / Eli Lilly Canada / Canada Safety Bulletin / / Country Canada / / / Facility Sunnybrook Health Sciences Centre / Hospital Pharmacy / / / IndustryTerm medication systems / healthcare / premixed infusion solutions / concentrated potassium phosphates solutions / chloride products / phosphate product / concentrated potassium solutions / healthcare failure mode / standardized dosing and monitoring protocols / infusion solution / site/media/documents/486_riskalertpsa01.pdf / / MedicalCondition severe hypophosphatemia / hypocalcemia / hypophosphatemia Hypophosphatemia / Moderate hypophosphatemia / hypophosphatemia / error-induced injury / mmol/L and severe hypophosphatemia / hypokalemia / / MedicalTreatment medication errors / intravenous infusion / Medication error / / Organization CACCN / Joint Commission / CACCN national office / Canadian Council on Health Services Accreditation / Patient Safety Service / Current CACCN / Institute for Safe Medication Practices / Canadian Association of Critical Care Nurses / National Patient Safety Agency / Intensive Care Unit / Sunnybrook Health Sciences Centre / / Person Patti Cornish / Sylvia Hyland / Dickerson / Christine Koczmara / / / Position Vice-President / Clinical Editor at the / bedside nurse / Pharmacist / senior medication safety analyst / Official / forward / R.N. / reporter / / Product potassium chloride / Safe Medication / sodium phosphates / Potassium Phosphates Injection / ISMP Medication / / ProvinceOrState New Brunswick / North Carolina / Ontario / / PublishedMedium The Official Journal / / URL www.caccn.ca / www.ismp-canada.org/download/ISMPCSB200311KCl.pdf / http / SocialTag 
ISMP Canada millimoles (mmol) for the phosphorus component, as well as inattention to the amount of potassium delivered with each dose.