GENERAL HEALTH INFO - Drugs in the News

Hello Everyone,

There has been an recent unfortunate medication error that has garnered alot of press. It appears that the twin children of the actor, Dennis Quaid were given an inappropriate dose of the anticoagulant drug, HEPARIN. Fortunately, the children are doing well and should make a full recovery.

Heparin is an anticoagulant that prevents the formation of blood clots in the body. It works by inhibiting the coagulation enzymes Thrombin (Factor IIa) Factor Xa and Factor IXa.

Heparin is used for the prevention of blood clots for patients that have had a heart attack, cardiac bypass surgery, prevention of blood clots in the legs and many other conditions where the formation of blood clots need to be prevented. The prevention of these conditions normally use higher doses of heparin. These doses are often called "Therapeutic doses"

Heparin is also used in lower doses for the prevention of blood clots forming in intravenous catheters or at the end of intravenous catheters. (Catheter Flush)

Heparin is not absorbed if taken orally so it must be given as an intravenous or subcutaneous injection.

The major side effect of heparin is unwanted bleeding. Heparin is also know as a "HIGH ALERT DRUG" A High alert drug is one that can cause significant harm to a patient even when used as intended. They cause harm more commonly and the adverse effects tend to be more serious.

I was asked, "How did this mix-up occur?"

Heparin is commercially available in many different strengths, reported as "Units/milliliter" (U/ML) (units/ml)

Because different conditions required different doses of heparin, most hospitals carry all the different strengths in their inventory.

Heparin is available in:

10,000 Units/ml \
5,000 Units/ml THESE ARE COMMON FOR THERAPEUTIC DOSES
1,000 Units/ml /

For Flushing Intravenous catheters the common strengths are:

100 Units/ml for adults
10 Units/ml for pediatric patients

In the incident with the Quaid children, they were supposed to receive a dose of the 10 Unit/ml Heparin but instead received a dose of the 10,000 Unit/ml heparin. That is a 1000 fold error.

See if you can see the potential for error in the following example:

Heparin 100u/ml IV as directed. - With the word "UNIT" not spelled out, the u could be mistaken for another zero. Therefore a dose of 1000 Units could be given instead of 100 units. Imagine if that order were hastily written out and not typed. It would be more difficult to read correctly. It can happen that easily!

There are many strategies out there to try to prevent these errors. The most important strategy is for the Pharmacists and Nurses to be constantly vigilant and aware that the potential for these errors exist. Check and Double check. If I am not sure, I ask. Then double check again!

For more information, please read the following from the Institute for Safe Medication Practices (ISMP)

http://www.ismp.org/Newsletters/acutecare/articles/20071129.asp

For information on High Alert Medications please see this link.

http://www.ihconline.org/ihi/ReduceHarmHighAlertMedications/PreventHarmFromHighAlertMedications.pdf

Thanks for your attention.

Dr. Paul