Heparin is widely used in a variety of settings for prevention and treatment of thromboembolic events. Data from a number of sources indicate that it is also one of the drugs most frequently associated with adverse events and medication errors, many of which are serious. National media attention has focused on recent events involving heparin and The Joint Commission has included heparin in its 2009 National Patient Safety Goal to reduce patient harm from anticoagulants. Heparin safety is on the national agenda and health care organizations are struggling to improve it. Health care providers in clinical, management, and executive roles must work together to improve heparin safety. Over 40 anticoagulation experts and practitioners came together in San Diego on March 13 through 14, 2008 to share information, offer perspectives, and address issues on the topic improving heparin safety. These individuals represented The Joint Commission, United States Pharmacopoeia, the Institute for Safe Medical Practices, academic institutions, large health care systems, and small hospitals who participated in a day and a half of presentations and round-table discussions. This article summarizes 21 presentations with a primary focus on types and frequency of heparin errors as well as identified opportunities to improve heparin safety. The conference was sponsored by Cardinal Health's Center for Safety and Clinical Excellence.

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