Safety Brief: Heparin Issue #2

With the current recall of many heparin products, hospitals are now receiving heparin in quantities, strengths, and packaging that are unfamiliar to staff. For example, hospitals that normally use heparin 5,000 units per mL vials may only be able to purchase 10,000 units per mL vials, and the volume in each vial may be larger than usual. We agree with readers who’ve shared their concern about potential dosing errors, especially in hospitals that maintain floor stock supplies or stock vials in automated dispensing cabinets (ADCs).

Hospitals that already have barcode scanning in place for both dispensing and bedside use are in the best position to prevent mix-ups, but sadly, fewer than one-third of hospitals use this technology today. Some hospitals have been applying auxiliary labels or otherwise calling attention to the unusual strength—even circling the concentration on vial labels with a pen or marker. Separating heparin vials of different concentrations can also help to prevent mix-ups.

One hospital recently reported that a nurse accidentally withdrew a heparin dose from a 5,000 units per mL vial instead of a 100 units per mL vial. The vials were located side-by-side in an ADC matrix drawer. Vials containing heparin flush solutions should be separated from vials containing therapeutic concentrations. The fact that heparin mix-ups and near misses continue—despite heavy media coverage following high profile mishaps and numerous warnings—illustrates how weakly many organizations embrace proactive medication safety strategies.

Selecting safe configurations for drug storage is one core safety strategy. But multiple error-prevention strategies, including independent double checks and barcode systems, are needed because each strategy protects in a different way, thus strengthening the overall resistance to errors. Examining the potential for heparin mix-ups and identifying all available strategies to prevent these errors helps to prioritize and implement the most effective ways to prevent errors. Unfortunately, organizations spend little time on interdisciplinary proactive safety planning unless the exercise is conducted as a requirement of The Joint Commission. How are you dealing with the shortage? Consider sending us an email (ismpinfo@ismp.org) to let us know what steps you are taking to avoid heparin errors associated with the wrong concentration.