Heparin is a potent anticoagulant, and one incorrect dose can lead to significant risk of an adverse drug event. During the solution-mixing process, staff might easily select an incorrect amount of heparin or an incorrect type or amount of solvent, without realizing they’ve done so. The solution would then be mixed incorrectly, but the label would indicate the intended dose and solution, making the error invisible to the person administering the drug. Human factors studies have shown that the risk of such errors is especially high when workers are busy, distracted, tired, or working in an environment not designed for safety. Using pre-mixed solutions reduces the possibility of an adverse drug event due to a mixing error. Pre-mixing also saves time for pharmacy and nursing staff.
- Prepare only one standard solution, to decrease confusion from multiple strengths. Physicians should work with the pharmacy in determining the strengths to prepare.
- Store only the standard strength on each unit.
- Make sure that the vendor supplying the pre-mixed solutions has good processes to prevent errors at its end. The processes should be at least the same as those you would use if mixing the solutions in your own organizations.
- Maintain heparin stocks and monitor them carefully, but have a well-defined plan for mixing solutions in case you run out.
- Urge all physicians to agree to use only the standard solution. Failing that, require peer review for any non-standard solution order, or for the record of any patient receiving a non-standard solution.
- Develop pre-typed orders and charts with drip rates based on dose; they are easy to use with a standard solution.
- Adopt protocols that let pharmacists and nurses adjust doses when certain criteria are met.
- Package the standard solution in a particular kind of bag to avoid selection errors. For example, never use a bag of heparin solution that is the same size as a pressure bag for arterial lines.