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Information from four voluntary reports of hospital-acquired acute hyponatremia leading to the death of otherwise healthy children is highlighted. In this column, we present two cases and information from a recent ISMP Canada Safety Bulletin, as well as two cases reported to ISMP United States. Information is shared to enhance health care practitioners' awareness of the potential for acute hyponatremia and to provide an overview of some of the potential underlying factors.


Christine Koczmara, Andrew W Wade, Peter Skippen, Mary Jane Campigotto, Kim Streitenberger, Roxane Carr, Elaine Wong, Karen Robertson. Hospital-acquired acute hyponatremia and reports of pediatric deaths. Dynamics (Pembroke, Ont.). 2010;21(1):21-6

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PMID: 20333891

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