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May 2012, Volume 42 Number 5 , p 10 - 10


  • Michael R. Cohen ScD, MS, RPH


After a code blue in an ED, a physician ordered heparin 50 units/kg for a patient weighing 70 kg (3,500 units) prior to transport for cardiac catheterization. A nurse removed four 10 mL vials of heparin (1,000 units/mL) from an automated dispensing cabinet. The drug concentration (1,000 units/mL, see vial at left) was misinterpreted as the total amount per vial, which led to preparation of a syringe containing 35 mL, or 35,000 units of heparin. A second nurse verified the dose without noticing the error. Two cardiac catheterization nurses questioned the unusually large dose but were told it had already been double-checked. The dose was given and the patient experienced significant gastrointestinal bleeding and a longer hospital stay.The United States Pharmacopeia (USP) has published notice of its intent to revise the labeling section of the USP Heparin Sodium Injection monograph to reduce the risk of this type of error. Currently the monograph requires that the label reflect the strength

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