Postoperative orders included IV fluids of “1000 cc D5W – 600 cc q8h.” An experienced pharmacist accidently calculated the infusion rate incorrectly and entered 200 mL/hour instead of 75 mL/ ...

regarding the death of a young patient who developed hyponatremia in response to desmopressin and post-op hypotonic IV solutions used to initially treat hypernatremia and central diabetes insipidus.

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