Heparin is widely used in hospitals for prophylaxis and treatment of venous thrombosis. Its potency, however, means that even small errors in preparing doses or solutions can lead to serious adverse drug events and cause significant harm to patients. By preparing all doses and solutions in the pharmacy, an organization can decrease the chance of errors occurring. That is, the fewer staff members who are involved in preparing doses and solutions, the easier it is to maintain competency and consistent practice. Staff members who work in the pharmacy may also encounter fewer distractions and interruptions than those in most patient care units. Heparin doses and solutions should arrive on patient care units in ready-to-use form, with no need for further manipulation by nursing staff.
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- Remember that errors can happen just as easily in the pharmacy as in other units.
- Arrange workspace and workflow to minimize the noise, phone interruptions, and pedestrian traffic that may distract staff members who are preparing doses and solutions.
- Store all heparin in the pharmacy to make it more difficult for staff that may attempt to prepare or mix doses on patient care units.
- Ensure that at least one trained staff member who routinely prepares heparin doses and solutions is always on duty. Inexperienced substitutes often commit errors.
- Have a plan to prepare doses and solutions for off-shifts if your pharmacy is not open 24 hours a day.
- Use a standard solution of heparin throughout the organization so the pharmacy needs to mix only one.
- Minimize the use of multiple strengths.
- Store different strengths separately and with clear labeling to help prevent selection errors.
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