How to Reduce Heparin Drips Administration Errors
Research on Nursing at Florida National University
How to Make Less Mistakes When Giving Heparin Drip
Introduction and statement of the problem
Heparin is an anticoagulant drug that is used for many things, like preventing and treating thromboembolism and managing central venous access. It comes in different concentrations, such as 1000 units/mL or more for therapeutic and preventative use and 100 units/mL or less for heparin lock flushing solutions. A lot of medical mistakes happen when people take heparin, which can have serious effects on their health (Warnock & Huang, 2019, p. 49). Three high-profile events at three well-known US institutions involving this medicine brought safety concerns about its use to the forefront. The Joint Commission’s National Patient Safety Goal (NPSG) 03.05.01, “Reduce the chance that a patient will be hurt by the use of anticoagulant medications,” focuses on the safe use and monitoring of anticoagulant therapies.
Even though a large hospital in the Midwest tried to use a computerized system to create standard procedures for giving heparin, mistakes kept happening at an unacceptable rate. In 2002, pharmacists, staff nurses, and cardiologists got together to form the Heparin Error Reduction Workgroup (HERW). The HERW hired human factors consultants to do an analysis of how the nursing staff gives out heparin based on human factors (Treiber & Jones, 2018, p. 159). Between 1999 and 2003, heparin was the most common drug that was taken by accident in the ED.
Heparin is a drug that can cause serious bleeding problems if it is used incorrectly. Over the past five years, it has become harder to figure out how much heparin to give in hospitals in big cities because of changes. Heparin used to be prescribed and monitored by doctors in a random way (Lee & Riley, 2021, p. 515). Dosage schedules for heparin were made and used to make sure that all doses were the same, that therapy was improved, and that risks were cut down. As heparin administration got more complicated and patient-specific, there were more ways to figure out how much to give. At first, the protocols were only written down on paper. Computerized access to drug administration was used to improve protocol delivery and increase the efficiency of upgrades. To make it easier to use protocols, interactive computer software was made.
In an Indiana hospital, mistakes with drugs led to the deaths of three premature babies. This caught the attention of the whole country. The newborns got too much Heparin because the flushing solutions for their umbilical lines were made with the wrong strength. Accidentally putting 1 mL vials in a unit-based automated dispensing cabinet (ADC) where heparin 10,000 units/ml, 1 ml vials were kept was what caused the mistake (Lee & Riley, 2021, p. 519). Nothing can take away the pain this terrible event has caused the families, and it keeps reminding us that we need to be more careful and look more closely at how heparin is used in our institutions.
Heparin is used to stop existing blood clots from getting bigger.
• How to treat pulmonary emboli and deep vein thrombosis and how to keep them from happening (Warnock & Huang, 2019, p. 49).
• Lessening the chance that blood clots will form. • Keeping indwelling venous catheters from getting clogged.
How important Heparin administration mistakes are to nursing.
Medication mistakes can happen at any stage of the process, including prescribing, transcription, dispensing, and giving the medicine. But research done in the past has shown that pharmaceutical mistakes happen more often when the drug is being given. This is because most of the drugs are given by nurses. Heparin, for example, is often given by nurses and watched over by them (Warnock & Huang, 2019, p. 49). The nurses get the clients’ prescriptions, send them out, and give them the medicine. Nurses can improve patient safety by stopping medication mistakes before they reach the patient by following six drug delivery rights and telling someone about the problem.
Nurses face problems in many parts of their jobs, but especially when giving and keeping an eye on medications. General drug information and knowledge, formal nursing education, the need for continuing education, clinical area experience, and the fact that there aren’t enough nurses in the country all affect how drugs are given to clients (Santomauro et al., 2021, p. 449). Other reasons include improvements in technology and programs to make things better. Patient safety is becoming more important, especially when it comes to drug therapies and high-alert drugs like unfractionated heparin (UFH). Certain ways of giving UFH can improve how patients are cared for. Because they are on the front lines of patient care, nurses are often in a good position to spot mistakes in the way drugs are made. On the other hand, for nurses to reach their goals, they must work closely with other health care providers.
The nurses should double-check how much medicine to give and give the right amount. The nurses might mix up the strength of the heparin, which could lead to a number of mistakes. Also, different types and strengths of heparin have different ways of being made and given. Errors also happen when different strengths of heparin are kept in the same place, when there isn’t enough documentation of the prescribed heparin in the ED, when there isn’t enough double-checking of the heparin dosage, and when the infusion pumps are programmed wrong (Gray, 2018, p. 369). The nursing staff often makes these kinds of mistakes. So, nurses should always check the heparin and write down what they did before giving it to a client. They should also check the heparin on their own to avoid making mistakes when figuring out how much medicine to give. They should also make sure that the infusion pumps are set up correctly so that the client’s blood doesn’t clot too much.
Why do research?
The goal of this study is to find out what goes wrong when heparin drips are given and how these mistakes can be fixed. There are a lot of mistakes made when giving heparin drips, which can cause serious problems or even death. Even though most of the mistakes that happen when heparin is given, like giving it to the wrong person, have gotten better, there have still been a few other mistakes. Out of every 1000 heparin doses charged, 2.01 mistakes happen. The mistakes happen when hospital staff, like pharmacists and doctors, don’t handle the heparin medicine correctly. However, most of the mistakes come from the nursing staff (Litman, 2018, p. 439). So, the goal of the research paper is to find out what goes wrong and how to stop it from happening again.
What do we know?
The goal of the research is to answer the following questions;
1. How often do mistakes happen when giving heparin drips?
2. What kinds of mistakes can happen when heparin drips are given?
How can mistakes be avoided when giving a heparin drip?
Conclusion
In many clinical settings, intravenous heparin is used to stop clots from forming. It is a high-risk drug that is usually given to people in hospitals, usually in critical care units. Most drug errors that lead to serious problems or death are caused by differences in how heparin is given. Some of these causes are mistakes in figuring out drug doses and making them. Errors with heparin drip infusion can be avoided by checking the dose and preparation of the medicine twice, programming the infusion pumps correctly, and writing down the dose of heparin that was given. But there is a need to learn more about the types of mistakes that can happen when heparin is given, what causes them, and how to avoid them so that the mistakes don’t cause as many problems.
References
Gray, G. (2018). Commentary: How Innovations in Infusion Systems Can Improve Care. 52(5):366-371 in Biomedical Instrumentation and Technology.
https://pdf.manuscriptpro.com/search/Abstract~30260667/1/cda77bb7/
Commentary:-Improving-Care-through-Innovations-in-Infusion-Systems.
Lee, M.H., and W. Riley. Factors that cause mistakes in the heparin dose-response test and suggestions for how to improve the management of heparin in cardiopulmonary bypass. Perfusion, 36(5), 513-523. https://pubmed.ncbi.nlm.nih.gov/32909506/ Litman, R. S. (2018). How do we prevent medication errors in the operating room? Take away the human factor. British Journal of Anaesthesia, 120(3), 438-440. https://pubmed.ncbi.nlm.nih.gov/29452799/ Santomauro, C., Powell, M., Davis, C., Liu, D., Aitken, L. M., & Sanderson, P. (2021). Interruptions to intensive care nurses and clinical errors and procedural failures: A controlled study of causal connection. Journal of Patient Safety, 17(8), e1433-e1440. 441-461. https://pubmed.ncbi.nlm.nih.gov/30113425/ Treiber, L. A., & Jones, J. H. (2018). Making an infusion error. Journal of Infusion Nursing, 41(3), 156-163. https://pubmed.ncbi.nlm.nih.gov/29659462/ Warnock, L. B., & Huang, D. (2019). Heparin. https://pubmed.ncbi.nlm.nih.gov/30855835/

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