While hospitalized, a 72-year-old patient was supposed to receive IV normal saline 0.9% (IV fluids). Instead, an order was placed for IV hypertonic saline 3%, which contains a high concentration of sodium and is used in cases of low blood sodium levels. However, this patient’s blood sodium levels were normal. MedAware alerted the care team of the mistake, and the order was canceled.

If treated with hypertonic saline, the patient could have suffered from dangerously high blood sodium levels, which could lead to neurological side effects such as dizziness, confusion, seizures, and even coma.