Name: _____________________________________________ Date: ________

Water, Water, Everywhere, But Please Don’t Give IV

https://www.ismp.org/resources/water-water-everywhere-please-dont-give-iv (excerpt)

Problem: The treatment of severe hypernatremia can be

challenging, especially in patients with preexisting conditions that
may seem to limit therapeutic options. Such a situation recently
resulted in an ill-conceived decision to give sterile water for
injection IV to an elderly patient who had been admitted to an ICU
with pneumonia and severe hypernatremia. The physician did not
want the patient to receive any further infusions containing
sodium. But the patient also was severely hyperglycemic. The
physician's concern with giving sodium or dextrose to a patient
with high blood sugar led to an order to change the patient's IV to
"free water" at 100 mL/hr.

"Free water" refers to water not associated with organic or

inorganic ions. Because hypernatremia usually results from a
deficit of "free water," it's likely that the physician intended to
replace this loss when he wrote the order. Water can be replaced
orally, however, it should never be given IV without additives to
normalize tonicity, or hemolysis may occur.

Just before writing the order, the physician had contacted a pharmacist to ask if "large bags of sterile water
for injection" were available. A pharmacy intern retrieved a bag from the sterile compounding area, placed
the label on the back of the bag, and dispensed it to the ICU.

The nurse began the infusion without question because she was aware of the patient's hypernatremia and
overheard the physician ask the pharmacist if bags of sterile water were available. She failed to see a red
statement on the bag stating "Pharmacy Bulk Package, Not For Direct Infusion" because the pharmacy label
was on the opposite side of the bag. Another nurse noticed the statement later and the infusion was stopped,
but not before 550 mL had infused. The patient experienced a hemolytic reaction, acute renal failure, and
died.

1. Hypernatremia means that there is an abnormally high concentration of salt in the blood.

The word hyper means “more.” What does “natremia” refer to? Sodium in the blood

2. Hypernatremia is a condition that can occur in anyone, especially athletes. It’s also a situation that can
occur where people do not have drinking water. Normally it does not require hospitalization and can be
resolved by doing a simple thing we all do every day. What can correct this condition in a normal, healthy
person?

Drinking water

3. Glycemia refers to the amount of glucose in a person’s blood. What does it mean that the patient was
hyperglycemic? Why did this affect the doctor’s decision to give the patient a normal IV?
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 Insulin or saline IV helps in controlling the blood glucose. When the insulin is produced in a sufficient
amount it remains inactive there will be an increase in the blood glucose levels. That is why the elderly
woman was given sterile watwe.

4. How is “free water” different from water that comes from a faucet or tap?

Free water is water not associated with organic or inorganic ions. Where tap water contains minerals.

5. How should “free water” have been administered to the patient?

Should not have gotten IV direct infusion. Should have took it orally

6. What is hemolysis, or a hemolytic reaction? (You may need to look this up.)

Rupture of red blood cells

7. What type of additives would be used to normalize tonicity? What’s in a normal IV bag?

Additives like salt should have been added in. Saline is in a normal IV bag

8. Why did the warning label on the bag say “not for direct infusion?” What does that mean?

Because patients with hypernatremia cant have direct infusion. This means they cannot have IV inserted
into them they must take it orally.

9. In your own words, explain why giving the patient sterile water contributed to her death.

The patients reactions were The patient experienced a hemolytic reaction, acute renal failure, and died.
She died because. This happened because she had sodium put into her body through IV when she
couldn't because she had hyperglycemic.

10. Suggest ways that this error could be avoided in the future.

Being more aware as the doctor, I thought of other options that would be beneficial for the patient.

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