![]() ![]() Nursing staff were immediately informed about the errors and educated about the changes at LPCH to prevent this type of error locally. All heparin flush solutions (10 units/mL and 100 units/mL) supplied by the pharmacy in automated drug-dispensing machines were changed to pre-filled syringes, thus minimizing the risk of “look-alike” vials. LPCH leadership added heparin to the hospital's “High Risk Medication List” and policy. At the next meeting of the Pharmacy & Therapeutics Committee, 10,000 units/mL heparin solutions were removed from the formulary, thus eliminating its use and availability in the hospital. All of the hospital's automated drug-dispensing machines (PYXIS) were checked for 10,000 units/mL heparin vials and none were found. Pharmacy personnel quarantined all 10,000 units/mL heparin solutions in the pharmacy. The same day the heparin overdose incident in Indiana was reported, members of the Pharmacy Department at Lucile Packard Children's Hospital (LPCH) at Stanford immediately took steps toward minimizing the risk of this error occurring at our institution. Unfortunately, some hospitals had not removed the old vials of heparin and replaced them with vials with the new labels when the second heparin error occurred. By October 2007, Baxter had revised the packaging and labeling of its 1,000 units/mL, 5,000 units/mL, and 10,000 units/mL heparin 1-mL vials. In this safety alert, Baxter acknowledged the Indiana incident and stated it was considering ways to differentiate the packaging of the two heparin solutions. ![]() In response to the first heparin medication error, the heparin manufacturer (Baxter in both incidents) released a medication safety alert on February 6, 2007. Other ISMP recommendations included minimizing look-alike packages & look-alike labels and move toward implementation of bar code verification prior to drug administration. 4 In this report, the ISMP recommended that hospitals re-evaluate their stocking process and reassess what should be removed from automated drug-dispensing cabinets. Immediately after the first incident in Indiana, the ISMP released a report on September 21, 2006, cautioning hospitals about the potential to repeat this medication error. ![]() System failures included: 1) failure to carefully and accurately read the label on the medication vial prior to administering the drug to the patient 2) inaccurate filling of automated drug-dispensing cabinets (substituting 10,000 units/mL 1-mL vials for 10 units/mL 1-ml vials) 3) non-distinct “look-alike” labels on the heparin vials 4) similar size of the heparin vials as both were 1-mL vials and 5) “factor of ten” dosing errors. Contributing Factors to the Heparin Medication ErrorsĪs frequently occurs, all of these heparin-associated medication errors happened when a number of system failures occurred simultaneously. ![]()
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