Matthew Kelberg
WARC 2017 Abstract
Poster Presentation: System and Practice-Based Projects
Title:
A systems-based approach to reducing heparin dosing errors in the cardiac catheterization lab at Seattle Children’s Hospital
Authors:
Matthew Kelberg, MD. PGY-3 (1)
Greg Latham, MD. Associate Professor (1,2)
Liz Martin, MD. Assistant Professor (1,2)
Affiliated Institution:
Seattle Children’s Hospital
University of Washington Medical Center, Department of Anesthesiology and Pain Medicine
Background:
Heparin is a high-risk medication as defined by the Institute for Safe Medication Practices. (3) At our institution, the cardiac catheterization lab is often staffed by rotating residents working in an unfamiliar environment with minimal experience prescribing, preparing and administering heparin. Mutiple heparin errors have occurred.
Case Description:
A seven month old girl presented to the cardiac catheterization lab for right heart and retrograde left heart catheterization, pulmonary angiography, aortic root angiography, right and left pulmonary artery balloon angioplasty, and embolization of an aorticopulmonary collateral. During the procedure, the interventional cardiologist requested that 50 units/kg of heparin be administered intravenously. The anesthesia resident calculated the dose to be 300 units of heparin and read this back before administering. The cardiologist confirmed the dose. Later, an ACT was found to be critical/undetectable. The attending anesthesiologist found that a 3 mL syringe had been used to deliver the heparin, and confirmed with the resident that 3 mL of 1000 units/mL heparin (or 3000 units) had been administered. Protamine 10mg was administered, and a repeat ACT was found to be within normal range. Direct pressure was applied for 10 minutes following removal of catheter, and there was no evidence of morbidity.
Discussion:
Incorrect dosing of heparin has occurred in our cardiac catheterization lab on more than one occasion. The most common error is a ten-fold overdose of heparin, which also occurred in this case. Sources of incorrect dosing can be traced to: incorrect dosing request, incorrect weight-based dose calculation, incorrect units per volume calculation, and incorrect volume administration. A simple read-back of the final volume to be administered has not historically reduced our rate of heparin errors, likely due to bias in hearing the expected dose and not the communicated dose. Therefore, we have instituted a standard process to minimize the risk of heparin errors. This process involves: 1) communication by cardiologist for anticipated heparin administration at pre-procedural “time-out,” 2) request for heparin dose in units/kg by cardiologist at the indicated time, 3) a two-provider independent verification of dose and volume with the catheterization lab nurse, and 4) a job aid to confirm the correct weight-based dose in both units and mL of heparin.
Figures:
Figure 1: Syringe used to administer heparin (how overdose was recognized).
Figure 2: Process flow chart illustrating opportunities for error and opportunities for recognizing/preventing error.
Figure 3: Weight-based dosing guideline for dose verification.
(1) Department of Anesthesiology and Pain Medicine, University of Washington
(2) Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital
(3) ISMP High Alert Medications. http://www.ismp.org/Tools/high...
