How to Reduce Heparin Drips Administration Errors

Heparin is an anticoagulant drug used for various uses, including thromboembolic prophylaxis and treatment and the management of central venous access. It comes in different concentrations (1000 units/mL or greater) for therapeutic and prophylactic usage and lower concentrations, that is 100 units/mL or less, used in heparin lock flushing solutions. Heparin administration is greatly associated with medical errors resulting in severe consequences on patients’ health (Warnock & Huang, 2019, p. 49). Three high-profile occurrences involving this medicine at three prominent US institutions brought safety concerns about heparin use to the forefront. The Joint Commission’s National Patient Safety Goal (NPSG) 03.05.01, “lower the chances of patient harm due to anticoagulant medication use,” emphasizes the safe anticoagulant therapy use and monitoring.

Despite a previous attempt in a large Midwestern hospital to develop standard heparin administration procedures using a computerized system, errors continued to occur at unacceptably high rates. Heparin Error Reduction Workgroup (HERW) was formed in 2002, by pharmacists, staff nurses, and cardiologists. The HERW hired consultants of human factors to conduct an analysis of the human factors process of heparin administration among the nursing staff (Treiber & Jones, 2018, p. 159). Between 1999 and 2003, heparin was the most commonly used medicine in 14,800 ED medication mistakes.

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Heparin is a medication that, if used wrongly, can result in serious hemorrhagic complications. Over five years, heparin dosing in large metropolitan hospitals with evolution has become more difficult. Heparin was formerly prescribed and monitored unevenly by physicians (Lee & Riley, 2021, p. 515). Heparin dose regimens were established and applied to ensure standardized dosing, optimized therapy, and reduced hazards. The dosing methods grew in number as heparin administration became more sophisticated and patient-specific. The protocols were originally only available on written paper. The benefits of computerized access in drug administration were exploited to improve protocol delivery and boost upgrade efficiency. Interactive computer software was developed to make protocol usage easier.

Three premature newborns died due to drug errors in an Indiana hospital that drew national attention. The Heparin overdoses were accidentally given to newborns because the incorrect strength was utilized to prepare umbilical line flushing solutions. The mistake occurred when 1 mL vials were accidentally put in a unit-based automated dispensing cabinet (ADC) where heparin 10,000 units/ml, 1 ml vials were commonly kept (Lee & Riley, 2021, p. 519). Nothing can take away the families’ pain in the aftermath of this unfortunate tragedy, and this keeps reminding us of the necessity to take precautions and closer examination of heparin use in our institutions.

The use of heparin includes;

· Prevention of enlargement of existing clots.

· Treatment and prevention of pulmonary emboli and deep venous thrombosis (Warnock & Huang, 2019, p. 49).

· Decreasing the risk of the development of blood clots.

· Maintaining patency of indwelling venous catheters.


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