Confusing Heparin Labels Can Lead to Errors

The Institute for Safe Medication Practices (ISMP) points out that some multiple dose heparin vials have potentially confusing labels that could lead to dangerous overdoses. These vials, which contain 4 mL of heparin solution, are labeled "10,000 USP units/ 1 mL," with the "10,000" in larger print than the rest of the designation. Because of this, someone quickly reading the label could assume that the entire vial contains 10,000 units. Calculating the patient's dose based on that mis-reading of the label could result in a fourfold overdose.

To help avoid this potential hazard, ISMP suggests that hospitals consider whether they need heparin in vials that contain more than 10,000 units per vial.

FDA Patient Safety News: April 2009

For more information, please see our website:
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/psn/transcript.cfm?show=85#6

Category:

Education

Tags:

• Heparin
• overdose
• medication error
• FDA

[alwaysopen]

I have a some relatively simple fucking solutions...

Print the labels in different colors - there are more than one, no? - and have the individuals administering the drugs check off on them as they would when giving whole blood or blood products. It may inconvenience someone for 5 minutes but it beats a code blue situation which necessitates locating a crash cart to push around the halls to resuscitate a dying patient - an inconvenience for everyone on duty on the floor.