Preventing Fatal Heparin Overdoses (Dec. 2006)

The Institute for Safe Medication Practices recently cited a case in which three premature infants died after receiving an overdose of heparin. According to ISMP, this may have occurred because heparin vials containing 10,000 units/mL were placed in an automated dispensing cabinet where vials containing 10 units of heparin per ml were normally kept. The vials looked somewhat similar, and the nurses did not notice that the ones that were taken from the cabinet actually contained 10,000 times more heparin than they expected.

ISMP notes that errors in filling automated dispensing cabinets are common, and so it is important to double-check the contents of these cabinets before they leave the pharmacy. The ISMP Alert lists several other steps to help prevent these kinds of errors. For example:

• Consider which medications might be removed from automated dispensing cabinets for safety's sake, especially in those cabinets that are used for high-risk patients such as neonates and children.

• Take steps to minimize look-alike packages and labels. When possible, do not stock items on nursing units that require further preparation before administration.

• Consider bar coding for medication administration management systems throughout the hospital, if not already in place. Even if bedside scanning is not being used, dispensing cabinet vendors provide bar code systems to make sure the right medications are stocked in these cabinets.

Additional Information:

ISMP Medication Safety Alert! Infant Heparin Flush Overdose. September 21, 2006.
http://www.ismp.org/Newsletters/acutecare/articles/20060921a.asp

Category:

News & Politics

Tags:

• Fatal
• Heparin
• Overdose
• FDA
• Infant
• Death
• Patient
• Safety