I'm sure you recall the well publicized medication error in November 2007 involving a celebrity's newborn twins receiving heparin for intravenous (IV) flush 1,000 times the intended dose while they were patients in a prominent hospital in California. Fortunately, these babies did not seem to suffer serious or permanent harm; however, in a similar case in Indiana in September 2006, three babies died. Human error and systems flaws were factors in both cases. It was reported that a pharmacy technician inadvertently placed vials with the wrong dose of heparin (Heparin Sodium Injection 10,000 units per mL) in the medication cabinet rather than the dose used to flush the IV (HEP-LOCK U/P 10 units per mL). This was an easy error to make given the same size of the vials of the different doses and the same color of the labels on the vials, although one is a slightly lighter color blue than the other (see picture). These vials are also quite small, just over an inch in height. Many nurses are getting older and sometimes it is difficult to clearly see small numbers. When you expect to see a vial of HEP-LOCK 10 units/mL after you have entered that specific amount into the automatic dispensing cabinet's computer and the drawer opens where the appropriate dose vials are usually stored, a nearly identical looking vial may not be cause for further scrutiny to make sure the dose is correct even though careful scrutiny should occur prior to administration of all medications. This appears to be the case in some of the reported heparin errors.
In February 2007, Baxter Healthcare Corporation, the company that produces the vials of heparin, issued an Important Medication Safety Alert warning to healthcare providers that the look-alike features of the two vials with vastly different doses presented a risk of "life threatening medication errors" (Deutsch, 2007). Baxter noted they were "considering ways to differentiate the packaging and labels to decrease the risk of medication errors" (Deutsch, 2007). In October 2007, over a year after the three deaths in Indiana, distribution of newly labeled heparin vials began, however vials with the previous labels were still used in many hospitals as evidenced by the November 2007 heparin error in California (Institute for Safe Medication Practices [ISMP], 2007a). ISMP (2007b) has designated heparin as a high alert medication (drugs that have a heightened risk of causing significant harm when used in error). More information about high alert medications can be found at http://www.ismp.org/Tools/highalertmedications.pdf.
No doubt the nurses in both errors were very caring and competent-however, the system failed them. When flawed systems are identified, immediate steps should be taken to remedy the problem before there is another near miss or patient injury. It is important to recognize that we all are at risk, along with our patients, for errors related to flawed systems. Yet, no system, however well designed, can prevent all errors. Personal vigilance in checking the five rights of medication administration (right patient, right drug, right dose, right route, right time) prior to giving medications is critical to our patients' safety.
Safe Medication Practices for Heparin
1. Remove all vials of concentrated of heparin solution (10,000 units/mL) from stock used in the neonatal intensive care unit.
2. Use prefilled syringes with package overwrapping color coded to the amount as well as printing with large fonts to identify the amount of heparin for administration.
3. Use barcoding and scanning prior to medication administration, including IV flush solutions.
4. Take the time to personally check the five rights of medication administration (right patient, right drug, right dose, right route, right time) prior to giving medications.
References