Osmotic Demyelination Syndrome from rapid correction of severe hypo/hypernatraemia

Through its review of recorded patient safety events, the National Patient Safety Team identified issues relating to identification and management of hyponatraemia (low blood sodium) including Osmotic Demyelination Syndrome, a critical condition caused when sodium levels are corrected too quickly.

As a result, the Royal College of Physicians (RCP) explored the issue in-depth, working across specialties, and found a number of complex and persisting issues with the recognition and management of hyponatraemia and also hypernatraemia (high blood sodium), both of which can result in patient harm and poor outcomes.

To better understand the issues and to inform recommendations for improvements, the National Patient Safety Team worked with the RCP to develop a successful application for a study to be undertaken by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). This study will investigate the incidence of severe hyponatraemia and hypernatraemia in hospital admissions across the NHS. The study will also examine the management pathways of patients to explore and provide crucial insight into multidisciplinary care and organisational factors in the process of identification, screening, assessment, and treatment.

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.

In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.