Desmopressin (dDAVP) incident signals the need for enhanced monitoring protocols.
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.
Campigotto
Mary Jane
MJ
Institute for Safe Medication Practices Canada (ISMP Canada).
Koczmara
Christine
C
Greenall
Julie
J
Hyland
Sylvia
S
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
D007038:Hypotonic Solutions; D012076:Renal Agents; D003894:Deamino Arginine Vasopressin