Sterile water should not be given "freely"
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Contributor(s):
- Pennsylvania. Patient Safety Authority. ECRI (Organization) Institute for Safe Medication Practices.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2008
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Fluid Therapy -- adverse effects Hypernatremia -- therapy Infusions, Intravenous -- adverse effects Water -- adverse effects Water-Electrolyte Imbalance -- complications Contraindications Fluid Therapy Hypotonic Solutions Product Packaging Risk Management Sodium -- blood Water -- administration & dosage Water-Electrolyte Imbalance -- therapy Medication Errors Osmolar Concentration Treatment Outcome Humans Pennsylvania United States
- Genre(s):
- Technical Report
- Abstract:
- Severe hypernatremia can be challenging to treat. There appears to be a failure among healthcare practitioners to recognize the danger of infusing plain sterile water intravenously. Bags of sterile water for injection and inhalation also are being mistaken for intravenous (IV) solutions. Sterile water is hypotonic (0 mOsm/L). Serious patient harm, including hemolysis, can result when it is administered by direct IV infusion. PA-PSRS and other medication error reporting programs have received reports of IV administration of sterile water to patients, some of which have resulted in patient deaths. Risk reduction strategies include recognizing the problem, developing protocols to treat hypernatremia, establishing safeguards, assessing for safe storage, and ensuring that sterile water bags cannot be provided without prior pharmacy agreement and supervision.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101569738 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101569738