More Regulation Of Heparin is Needed to Avoid Deaths, Injuries
Friday, September 26, 2008
The commonly used blood-thinning drug heparin has caused dozens of deaths and serious injuries in recent years. Many of the injuries were preventable if hospitals had taken steps to prevent mistakes in administering heparin and other blood thinners, according to a national hospital accreditation agency.
The Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 15,000 health care organizations and programs in the United States, is urging hospitals to adopt stricter standards for the use of anticoagulants like heparin. The commission issued a safety alert to hospitals on September 24, 2008.
By taking time to double-check their work, carefully monitoring patients on blood thinners, and taking other preventative measures, nurses and other hospital workers can greatly reduce the number of fatal and life-threatening injuries caused by mistakes involving heparin and other anticoagulants, the commission said.
An estimated 28 deaths were caused by drug errors involving heparin and other blood thinners between 1997 and 2007, according to the commission. A total of 59,316 medication errors involving all blood thinners were reported between 2001 and 2006 and nearly 3 percent, or roughly 1,700 cases, resulted in patient injuries or death.
Product Packaging Blamed for Heparin Errors
Many errors involving heparin are the result of confusing product packaging and the fact that there are different types of heparin designed for different uses. Hep-Lock is a form of heparin designed to prevent blood clots and clear intravenous lines in young patients. Heparin is intended for use in adults and is approximately 1,000 times stronger than Hep-Lock.
Despite the distinct differences between heparin and Hep-Lock, the products are packaged in nearly identical vials, with similar lettering and blue-white coloring. In many cases, nurses, pharmacists, and other hospital personnel have mistaken the two drugs, leading to devastating injuries. An overdose of heparin results in excessive bleeding that can be difficult to stop, particularly in newborn infants.
Actor Dennis Quaid’s Children Injured
Confusion between heparin and Hep-Lock was blamed for life-threatening injuries to the newborn twins of actor Dennis Quaid and his wife in November 2007. The babies were mistakenly given multiple doses of heparin instead of Hep-Lock and nearly died. The mistake occurred because the hospital pharmacy stored vials of heparin alongside doses of Hep-Lock and the nurse administering the medication to the Quaid twins failed to verify that she had the correct dosage.
The Quaid twins recovered from their injuries after drastic measures were taken to prevent them from bleeding to death. In December 2007, the couple sued Baxter Healthcare Corp., the maker of heparin, alleging the product’s packaging caused the confusion. Cedar-Sinai Medical Center, where the injuries occurred, was fined $25,000 by state health regulators for the heparin mix-up.
Other recent cases of heparin mistakes include an incident in July 2008, when 14 newborns were given accidental overdoses of heparin at a hospital in Corpus Christi, Texas. Those overdoses were also blamed on mix-ups between adult-strength heparin and Hep-Lock.
Joint Commission Urges New Safety Measures
The Joint Commission urged hospitals to adopt new safety measures and procedures in an effort to avoid mistakes in administering heparin and other anticoagulants. Among the commission’s recommendations were:
• Use bar-code technology or computerized prescriptions
• Closely monitor patients on heparin and blood-thinners
• Store doses of adult-strength heparin away from units of children’s Hep-Lock
The commission said it will send investigators on unannounced visits to make sure hospitals are adopting tougher measures to prevent blood thinner errors and may revoke the accreditation of hospitals that do not comply.
Simple Steps Can Save Lives
In the case of heparin, lives can be saved and serious injuries can be prevented with a simple dose of caution. By taking a few seconds to double-check medication bottles and pharmacy orders, nurses can prevent dozens of deaths and serious injuries. When a little effort can save a patient’s life or prevent a life-threatening complication, the choice to take a little extra time and make sure everything is correct should be an easy one.
Posted under: Dangerous Drugs • Heparin