Sterile water should not be given "freely"

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
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