title: Desmopressin (dDAVP) incident signals the need for enhanced monitoring protocols.
abstract: In this article, the authors highlight the circumstances surrounding the death of a young adult neurosurgical patient, recently reported to ISMP Canada. The incident signals the need for enhanced safeguards for patients receiving desmopressin (also known as dDAVP) and intravenous therapy. The authors present information from a recent ISMP Canada Safety Bulletin relevant to critical care, including an outline of potential contributing factors and suggested recommendations.
authors.affiliation: Institute for Safe Medication Practices Canada (ISMP Canada).
authors.forename: Mary Jane
authors.initials: MJ
authors.lastname: Campigotto
authors.forename: Christine
authors.initials: C
authors.lastname: Koczmara
authors.forename: Julie
authors.initials: J
authors.lastname: Greenall
authors.forename: Sylvia
authors.initials: S
authors.lastname: Hyland
mesh_terms: D016907:Adverse Drug Reaction Reporting Systems; D001932:Brain Neoplasms / Q000601:surgery; D002170:Canada; D003422:Critical Care / Q000379:methods; D003894:Deamino Arginine Vasopressin / Q000009:adverse effects*; D003919:Diabetes Insipidus / Q000139:chemically induced / Q000175:diagnosis / Q000517:prevention & control; D016903:Drug Monitoring / Q000379:methods*; D017809:Fatal Outcome; D006801:Humans; D007010:Hyponatremia / Q000139:chemically induced / Q000175:diagnosis / Q000517:prevention & control; D007038:Hypotonic Solutions / Q000009:adverse effects; D007262:Infusions, Intravenous / Q000009:adverse effects; D008508:Medication Errors / Q000379:methods / Q000451:nursing / Q000517:prevention & control*; D009730:Nursing Assessment; D011182:Postoperative Care / Q000379:methods; D012076:Renal Agents / Q000009:adverse effects*; D017751:Safety Management / Q000458:organization & administration
chemical_list: D007038:Hypotonic Solutions; D012076:Renal Agents; D003894:Deamino Arginine Vasopressin