Approved Hospital Formulary
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Approved Hospital Formulary
04/26/2021 jr Correcting an IV fluid order
April 28, 2021
From: "Jerry Robinson Pharm.D." <jerry.robinson@hhsys.org>
To: "Pharmacists" <allpharm@hhsys.org>
Sent: Monday, April 26, 2021 1:43:52 PM
Subject: Correcting an IV fluid order
Scenario
The order was transcribed to be 2 liters of D5W instead. After the patient was receiving the first liter of D5W, the wrong fluid type was noticed.
What would be the appropriate fluid to change the patient to?
In this example, 1 Liter of NS was given to attempt to equal the original orders, giving the patient 1 L of D5W and 1 L of NS.
Best practice would be: change to the original order fluid and notify the prescriber of the mistake.
What's the difference:
If you give the 1 liter of D5W and 1 liter of NS, you have given the patient: 50 g dextrose and 154 mEq sodium chloride
If you give 2 liters of D5NS, you have given the patient: 100 g dextrose and 308 mEq sodium chloride
Thanks for continuing to report near misses and medication errors to improve our system.