Accidental death due to erroneous intravenous infusion of hypertonic saline solution for hemodialysis

Int J Artif Organs. 2004 Sep;27(9):810-2. doi: 10.1177/039139880402700912.


The case of a continuous hemodialysis patient who died shortly after erroneous infusion with undiluted hypertonic solution is reported. Autopsy showed small parenchymal hemorrhages in all organs. Although producers take measures to prevent such errors by hospital staff, further steps are suggested for types of dialysis requiring reinfusion of large quantities of reinfusion hemodialysis solution.

Publication types

  • Case Reports

MeSH terms

  • Adult
  • Fatal Outcome
  • Hemodialysis Solutions / administration & dosage*
  • Hemofiltration / adverse effects*
  • Humans
  • Infusions, Intravenous
  • Male
  • Medication Errors / adverse effects*
  • Saline Solution, Hypertonic / administration & dosage*


  • Hemodialysis Solutions
  • Saline Solution, Hypertonic