Hospital-acquired hyponatremia risks and solutions: ISMP Canada

ISMP Canada has released its first bulletin in nearly a decade that focuses on hospital-acquired hyponatremia. Acutely ill patients are often prescribed IV fluid therapy, and hospital-acquired hyponatremia “continues to be an important risk for hospital inpatients,” the organization says. It says there are three key aspects to patient safety to prevent hyponatremia: IV fluid selection, electrolyte monitoring and recognizing the signs and symptoms of hyponatremia. The new review looks at incidents that occurred over a recent five-year period. The data were taken from the Canadian Institute for Health Information’s National System for Incident Reporting.Read: ISMP Canada analysis highlights errors that can happen with look-alike high-alert medicationsIn 2015, ISMPC highlighted two causes of the condition: prescribing the wrong intravenous solution and having the wrong amount of the IV solution infused. Since then, there has been a higher awareness of the potential harm that can come from this type of therapy, it said. It also said there was a better understanding of and recognition of which IV fluid treatment was most appropriate for patients based on their clinical status. Groups like the Canadian Paediatric Society have also been promoting the appropriate use of IV fluids and other safety improvements, such as packaging, the group said. All of the incidents in the five-year period the ISMPC looked at were discovered by nurses during routine checks, suggesting newer processes for monitoring therapies lead to catching more errors. Unfortunately, not all were caught promptly. One error wasn’t detected until three days later, and another led to a patient having a decreased level of consciousness. That’s because when serum sodium levels drop, water moves to brain cells, causing swelling. Decreasing consciousness is one result, and that can deteriorate into comas, brain herniation and death. Read: The five most common e-prescribing errors: ISMP CanadaInitial symptoms are less severe, including irritability or fussiness, nausea or vomiting, headache, muscle cramping and lethargy. The bulletin shares the importance of promptly treating acute hyponatremia before patients deteriorate, and highlights vulnerable patients, such as those under 18 and older adults. Most of the errors were caused by the wrong fluid being selected and administered. In cases where an isotonic fluid was ordered but a hypotonic IV fluid was given instead, ISMPC found several contributing factors. They were incorrect storage of the IV solutions on the IV storage cart, IV bag labels having a similar appearance, not having the IV fluid included in the medication administration record and not having laboratory monitoring that could have identified the incorrect IV solution. Other issues were delays in identifying possible symptoms of hyponatremia and trouble differentiating hyponatremia from other conditions with similar symptoms. ISMPC offered recommendations for acute care organizations, pharmacy teams, nursing teams and prescribers. Recommendations for nurses include checking the IV fluid and rate of infusion against the medication administration record or nursing care plan, or both, at the beginning of their shift; promptly reporting critical laboratory results to the most responsible physician; and reassessing whether ongoing IV therapy is needed each day.For organizations, ISMPC’s suggestions included using technology like bar codes to make sure units are correct and engaging patients and families to watch for signs or symptoms of hyponatremia and to monitor parameters. The recommendations for pharmacists included encouraging them to confirm a valid indication and monitor electrolyte results if hypotonic fluids are prescribed for high-risk patients, and including pharmacy technicians in education about which IV fluids to use and when. Finally, it advised prescribers, including telling them to prescribe isotonic IV fluids unless they’re treating a clinical condition or a specific fluid or electrolyte disturbance, or there are contraindications, and to ensure there is regular electrolyte monitoring. More information can be found here.Read: Eight ways healthcare professionals should create safe spaces for patients: ISMP Canada

Hospital-acquired hyponatremia risks and solutions: ISMP Canada

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