Improving Heparin Safety: A Multidisciplinary Invited Conference

Abstract

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.

Engineered virus-like nanoparticles reverse heparin anticoagulation more consistently than protamine in plasma from heparin-treated patients

“…Despite its ubiquity in clinical settings, bleeding is a common and serious complication of heparin therapy [1,2]. Therapeutic UFH is a naturally occurring glycosaminoglycan that is purified from pig or bovine tissue as a heterogeneous mixture of polysaccharide chains with variable molecular weight (5–30 kDa, average 15 kDa) [3,4].…”

Second Consensus Development Conference on the Safety of Intravenous Drug Delivery Systems—2008

“…In response to recent errors, there have been several conferences convened on medication safety, including a multidisciplinary invited conference on improving heparin safety sponsored by Cardinal Health Center for Safety and Clinical Excellence in March 2008. 5 At this conference, participants from ISMP, USP, the Joint Commission, academic institutions, large health care systems, and small hospitals discussed issues surrounding the safe administration of heparin. Material presented addressed the frequency and distribution of heparin errors; clinical issues with the use of heparin, such as variations in dosing protocols, appropriate timing of tests for monitoring heparin safety, and the sensitivity of reagents used for monitoring of heparin therapy; programming errors with the use of infusion devices for heparin; lack of human-factors considerations involved in process and device use with heparin; and recommendations to improve heparin safety within health care organizations.…”