Antidote for heparin overdos11/21/2023 ![]() Errors with heparin gained widespread media attention 4 years ago after several infants in Indiana died from an overdose of heparin during routine flush procedures, and after newborn twins of actor Dennis Quaid could have died from a similar overdose caused by mix-ups between vials containing 10,000 units/mL and 10 units/mL. 8 Since 1996, we have published more than 100 reports in our acute care newsletter alone about errors with heparin, many fatal, all serious. 7 Just a year later, the drug was again identified during a national benchmarking study as one of six drugs most frequently involved in serious and fatal events. ISMP identified heparin as a high-alert medication more than 20 years ago, when it appeared on our very first list of high-alert medications. Although the reasons for not employing the technology are unclear, studies about smart pump implementation have provided some insight into why clinicians bypass the dose-checking technology: falsely low perceptions of risk failure to make adjustments in the drug library when alerts are not credible extra work needed to use the technology lack of standard drug concentrations and dosage methods time constraints clinical emergencies and a culture that inadvertently supports technology workarounds. The pump involved in the event was a smart pump with a drug library and dose-checking capabilities, but apparently this feature was not being utilized at the time of the event, or at least not used to its fullest extent so an error of this nature could have an opportunity to be quickly recognized. Things we have learned from our error-reporting program suggest that failed double-checks happen most often when: the check does not occur independently the process is informal and lacks the highest regard for the substantial responsibility the checker takes on both the initiating person and checker fall victim to the same external conditions causing the error (e.g., look-alike packaging) or distractions and other environmental conditions reduce staff attention to detail. Exactly how the verbal check occurred and why it did not uncover the error have not been made public. The wrong dose of heparin infused for about 5 hours before the error was noticed. The overdose occurred due to an infusion pump setting error that was not detected during a verbal checking process. 1-3 While the investigation may take several weeks to complete, here is what we can piece together from the media reports so far. ![]() News reports about this error suggest that hospital leaders plan to share the details of the event with the healthcare community nationwide to help prevent this from happening to another child. ![]() During the infusion, the child received a large overdose of heparin, which led to cerebral bleeding and subsequent brain death. The child’s condition was critical, and she required renal dialysis and an intravenous infusion of heparin to prevent clotting. She progressed satisfactorily and was discharged in February 2010 but readmitted about a week later with a viral illness and infection that resulted in renal failure. The child was brought to a Nebraska hospital in early December 2009 where she underwent transplantation of the small bowel, liver, and pancreas. The child was born in Texas with gastroschisis (protrusion of the intestines) and had undergone various procedures and hospitalizations before her physicians determined that a transplant was necessary. The deadly effect of a heparin error made the headlines again, this time claiming the life of a toddler about to celebrate her second birthday.
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