Project Information

UFHealth Shands Children’s Hospital reduction in incidence of hospital acquired hyponatremia quality improvement initiative

Project Description: Over the past year, at least 77 inpatient pediatric patients without an admitting diagnosis of hyponatremia were diagnosed with hyponatremia during their admission. This is likely a significant undercount as it was reliant upon ICD 10 code entry, and likely only reflects those that were symptomatic, triggering problem-list coding. One of these children died, and at least one required a prolonged PICU stay to correct hospital acquired hyponatremia which was due to inappropriate IV fluid selection. This project will begin with phase 1 (review of ordersets used in inpatient peds areas for hypotonic IV fluids, educational component of providers) followed by phase 2 if needed (implementation of a "hard stop" in EPIC requiring provider to answer safety questions prior to ordering hypotonic fluids on pediatric patients, phone call from TPN pharmacist prompting ordering provider to review tonicity of TPN ordered). A steering committee consisting of stake holders from various areas of the children's hospital will be put into place prior to beginning this project and will meet monthly for one year.

QPI: Charlene, Leonard, (

Collaborators: Torrey, Baines, (; (; (


UF Health Big Aims: Zero Harm None

MeSH Keywords: Hyponatremia, iatrogenic, pediatric, inpatient, hospital-acquired