med errors: avoiding heparin dosing mistakes
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Med Errors: Avoiding Heparin Dosing MistakesAuthor(s): Linda L. Lilley and Robert GuanciSource: The American Journal of Nursing, Vol. 97, No. 12 (Dec., 1997), p. 12Published by: Lippincott Williams & WilkinsStable URL: http://www.jstor.org/stable/3465514 .
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MEDERRORS By Linda L. Lilley, PhD, RN, and Robert Guanci, MBA, RPh
Avoiding Heparin Dosing Mistakes
Look at the label-and then look again.
T he change of shift is ap- proaching on the cardiac stepdown unit. At 11 PM
you receive a report from the ED on Simon Lowell. When
Mr. Lowell arrives on the unit 20 min- utes later, you note that the physician's order calls for a heparin drip per proto- col. You begin to gather the supplies to mix 25,000 U of heparin in 250 mL of 5% dextrose in water.
As the orders are being transcribed to the medication administration record, you page the nursing supervisor. She takes a copy of the medication order and retrieves three familiar-looking vials of medication from the pharmacy, which is closed until 6 AM. When the nursing supervisor returns with the heparin, she mixes the solution while you're attending to another admission. The supervisor withdraws the contents of two and a half vials of heparin, spikes the bag, and hangs it at the patient's bedside. As you walk past the medica- tion preparation area, you notice the vials lying on the counter. On inspec- tion, you see that the vials are labeled "10,000 U/mL 4 mL."
You immediately go to the patient's room, remove the bag, and inform your supervisor of the matter
Sound familiar? Many of us have found ourselves in situ- ations where misreading of labels has led to a medication error or a "near miss." Heparin, in particular, continues to fig-
Linda L. Lilley is an associate professor at Old Dominion University School of Nursing, Norfolk, VA. Robert Guanci is administrative director of pharmacy and ancillary services at Virginia Beach (VA) General Hospital.
ure frequently in such events. As in this case, when it comes to solu-
tions with different strengths, it's not always easy to see from the label how much drug is in the container. The super- visor misread the vials as each contain- ing 1 mL of solution (and 10,000 U) while each actually contained 4 mL (and 40,000 U). The supervisor withdrew two and one-half vials of solution for a total dose of 100,000 U-a fourfold overdose.
What would help? The goal of analyzing the elements of a medication error is to reduce the chance of it happening again. Let's look at how the heparin dosing error could have been prevented.
* Had the supervisor adhered to the Five Rights of medication administra- tion, she would have more carefiully read the medication label. This step is particu- larly critical when the concentration and amount of solution in the vial may not be the same as that prescribed. Read the label on the vial before drawing up the dose, calculate the correct dose and draw it up, and immediately check the label again.
All heparin orders and subsequent prepared solutions should be double- checked with another nurse. The vials the solution was drawn from and the amount of solution in the syringe should be double-checked. Had this taken place in the case in question, the error would have been detected before the infusion reached the patient's room.
* A 24-hour pharmacy is essential in today's health care systems to handle the volume of medication orders and reduce the number of individuals who directly
obtain medication for distribution on the unit. The supervisor obtained vials that were familiar-looking. Without 24-hour accessibility of qualified pharmacy per- sonnel, the institution loses double-check safeguards that would prevent an error like that made in this situation. Had the pharmacist been present, the nurse most likely would not have left the pharmacy with three vials of the wrong dosage.
Prevention is a team effort To uncover the roots of the problem within the medication administration process, like recurring heparin dosing errors, look at the entire system and ask questions. Recurring errors in prepara- tion may justify switching to the pre- mixed fluids in a standard dilution.
Development of preventive measures, such as publicizing common errors or near errors, reducing the number of available concentrations or dose strengths of a drug, and reconsidering which agents should be floor stock, should include all participants in the medication administration system- staff nurses, nursing supervisors, phar- macists and pharmacy staff, physicians, and the auxiliary personnel who tran- scribe orders. The more we educate one another, the more we can protect our patients from harm and improve their care. O
AJN / December 1997 / Vol. 97, No. 12 / http://www.nursingcenter.com 12
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