ABSTRACT
Information from four voluntary reports of hospital-acquired acute hyponatremia leading to the death of otherwise healthy children is highlighted. In this column, we present two cases and information from a recent ISMP Canada Safety Bulletin, as well as two cases reported to ISMP United States. Information is shared to enhance health care practitioners' awareness of the potential for acute hyponatremia and to provide an overview of some of the potential underlying factors.
Subject(s)
Fluid Therapy/adverse effects , Hyponatremia/etiology , Hypotonic Solutions/adverse effects , Medical Errors/statistics & numerical data , Acute Disease , Canada/epidemiology , Child , Child, Preschool , Critical Care , Fatal Outcome , Hospitalization , Humans , Hyponatremia/mortality , Hyponatremia/prevention & control , Medical Errors/nursing , Medical Errors/prevention & control , Nursing Assessment , Risk Management , United States/epidemiologyABSTRACT
In this article, the authors highlight the circumstances surrounding the death of a young adult neurosurgical patient, recently reported to ISMP Canada. The incident signals the need for enhanced safeguards for patients receiving desmopressin (also known as dDAVP) and intravenous therapy. The authors present information from a recent ISMP Canada Safety Bulletin relevant to critical care, including an outline of potential contributing factors and suggested recommendations.
