Volume 11,Issue 1
Reassessment of Fatal Cases of Hypokalemia from a Pharmaceutical Perspective: Medical Quality and Safety in Terms of Rational Drug Use
Objective: This study aimed to conduct a pharmaceutical evaluation of a fatal medical accident caused by hypokalemia, identify medication risks and management deficiencies in primary healthcare institutions, and propose targeted strategies to improve rational drug use and medical quality assurance. Methods: A case involving a 53-year-old male patient treated at a township-level health center in southwestern China was reviewed. The analysis was based on the patient’s clinical course and the official medical accident appraisal report. The study focused on pharmaceutical aspects, including intravenous medication strategies, electrolyte disorder management, drug contraindications, and emergency value handling. Results: Multiple medication safety issues were identified in this case, including the failure to recognize and intervene in severe electrolyte imbalances on time, insufficient potassium supplementation, inappropriate use of contraindicated drugs (compound glycyrrhizin), delayed response to critical laboratory values, and lack of pharmacist involvement. These deficiencies, in the context of the patient’s underlying conditions, significantly increased the risk of arrhythmia and cardiac arrest, ultimately resulting in a fatal outcome. Conclusion: Pharmacists should play a proactive role in primary healthcare by participating in treatment planning, enhancing the identification and management of high-risk medications, and contributing to the establishment of emergency value response systems. A standardized, individualized approach to medication management is essential to improving the overall quality and safety of healthcare services.
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