Strict Heparin Rules Needed at Hospitals, Regulators Say
September 30th, 2008 laurie
Last week the Joint Commission, a regulatory group, told hospitals they should adopt strict rules to help prevent dosage errors and other medical mistakes involving blood thinners including heparin. The Associated Press reports that as many as 60,000 such mistakes have been made in recent years, leading to dozens of deaths.
Some of these heparin errors have make news headlines in recent months. In July, several babies in Texas received accidental overdoses; newborn twins died. Last year, Dennis Quaid’s newborn twins received an accidental overdose of heparin; his twins lived, by some miracle.
The AP reports on the Joint Commission’s safety alert, which says hospitals need to adopt prevention measures that could include bar-coding technology for medicines or computerized drug orders. It advised hospitals to more closely monitor patients on these drugs and make sure that adult-strength heparin is stored nowhere near children’s units.
According to the Joint Commission’s website, lack of standardization for the naming, labeling and packaging of anticoagulants creates confusion. For example, heparin flush syringes have been confused with LMW heparin syringes. In addition, other, lesser-known anticoagulant drug names exist (e.g., enoxaparin, dalteparin, tinzaparin) and are used less commonly, which can result in duplicate medication orders and erroneous dosing.
The Joint Commission’s Sentinel Event Database includes 446 medication-related sentinel events reported from January 1997 through December 2007, with 32 of these involving anticoagulants; of those, two-thirds 21 involve heparin. According to the United States Pharmacopeia MEDMARX database, a total of 59,316 medication errors related to anticoagulants were reported to the MEDMARX program from 2001 to 2006 (these data do not include errors involving heparin lock flush). Nearly 60 percent of these errors reached the patient and nearly 3 percent resulted in harm or death.
Commission investigators will make unannounced visits to make sure hospitals are adopting strict measures to prevent blood thinner errors, and those who fail to do so could see their accreditation revoked, the AP reports.
