Otsuka ICU Medical, LLC Issues Voluntary Nationwide Recall of 20 mEq Potassium Chloride Injection Due To Overwrap Mislabeled As 10 mEq Potassium Chloride Injection
Otsuka ICU Medical LLC is issuing a voluntary recall to the user level for a mislabeled lot of POTASSIUM CHLORIDE Inj. 20 mEq, NDC 0990-7077-14. The overwrap label of lot 1030613, expiration date 09-30-2026, may incorrectly identify the product as POTASSIUM CHLORIDE Inj. 10 mEq with NDC 0990-7074-26. Otsuka ICU Medical LLC has identified this discrepancy due to a manufacturing issue. The dosage is correctly printed on the labeling affixed to the product bag, which is not visible when the 10 mEq OVERWRAP is in place. This notification details the issue and the required steps for you to perform.
If the incorrect dosage on the 10 mEq overwrap is used instead of the correct 20mEq dosage printed on the product, an overdose of potassium chloride is possible. Overdose of potassium chloride can lead to hyperkalemia. Hazards of severe hyperkalemia after large intravenous overdoses causes neuromuscular dysfunction, including muscle weakness, ascending paralysis, listlessness, vertigo, mental confusion, hypotension, cardiac dysrhythmias, or death from cardiac arrest.
Premature infants, patients on chronic parenteral nutrition, patients who have a history of cardiac arrythmias, patients with chronic renal insufficiency, patients who have acute renal failure, patients on potassium-sparing diuretics—all are at risk for adverse and potentially fatal outcomes. Otsuka ICU Medical LLC has not received reports of adverse events associated with this issue to date.