Many heparin products have been recalled because of possible contamination, so your facility may be receiving heparin in unfamiliar quantities, strengths, and packaging. If you normally use 5,000 units/mL vials of heparin, but can get only 10,000 units/mL vials, you'll need to be extra alert for dosing errors.

Even keeping unit stock in automated dispensing cabinets (ADCs) doesn't preclude errors. In a recent incident, a nurse accidentally withdrew a heparin dose from a 5,000 units/mL vial instead of a 100 units/vial. The two concentrations were side by side in an ADC drawer.

Separate heparin in different concentrations (heparin for flush solutions versus therapeutic dosages) and continue to use independent double checks and bar-code systems. Institute multiple error-prevention strategies because each strategy protects in a different way, reducing the odds of an error slipping through.

If you have a strategy for dealing safely with the heparin shortage, e-mail the Institute for Safe Medication Practices at [email protected].