Message from the President
It Happened Again! Heparin Errors: A Marker for Safe Practices
Judith Jacobi, PharmD, BCPS, FCCM
Critical Care Pharmacist, Dept. of Pharmacy
Methodist Hospital/Clarian Health Partners
Indianapolis, Indiana, USA
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Recent headlines revealed another death due to an unintentional overdose of heparin administered to a child. How can this happen when we know about high-risk drugs and vulnerable populations? Is heparin the problem? If we had another, safer anticoagulant, would the problem be solved? Was the caregiver inexperienced, untrained or careless?
While some responsibility for such adverse events falls to the individuals involved, most often the errors signal a system related problem – a crisis just waiting to happen. When neonates in my hospital received adult doses of heparin instead of a heparin flush, the results were devastating. When it happened again in California, the patient outcome was better, but the message was clear: It can happen anywhere.
Heparin was labeled as a high-risk drug almost 20 years ago, along with insulin, vasoactive medications, opioids and many other potent medications. No medication is safe in all circumstances, but some clearly are associated with a greater risk due their nature, side effects, narrow therapeutic range or use in vulnerable patients. Identifying high-risk medications was the first step toward developing safe practices and technology. Expansion of such practices to broader groups of medications was planned in parallel with growth of the safety climate.
So why has that not happened to the degree that prevents serious adverse events? Do you think it can’t happen at your institution? Do you believe your practitioners are smarter or more careful? Have you been too busy to evaluate safety processes? It is easy to justify a deficiency of safety focus when we believe in our team and our systems, but now is the time to learn from the misfortune of others.
Examine your safety practices prospectively, but don’t concentrate on just one aspect or drug. Think about all of the interactions we have with patients every day. Are you doing all that is needed to prevent problems? Are you following safe practices routinely and systematically? Are you using medications safely? Ask your team members to pretend they are regulatory inspectors and have them evaluate their own work.
Start Simple: Divide and Conquer
Select a focused group of tasks and evaluate only one or a few at a time. Let’s use heparin as an example and examine the process for prescribing, stocking, delivering, administering and monitoring. Orders must be written clearly or – even better – be issued in a computerized process that ensures a standard concentration, correct weight-based dose, and accurate calculation. Calculations also can be done automatically using a “smart” pump. Speaking of weight, which weight are you using? Intensive care unit (ICU) patients have an admission weight (likely higher than the estimated weight), a daily weight (likely to be very different), a lean weight and a dosing weight. Although there is limited information to identify which weight is correct, are you at least consistent in your selection? Be sure there is an order for platelet monitoring and that partial thromboplastin time (PTT) tests are not only ordered, but performed on time and evaluated. Finally, go to the bedside and watch the administration process to ensure it is streamlined and consistent. Have you created such a complex process in the name of safety that inconsistency has been exacerbated? Has the safety technology been utilized to its full potential? The best pumps in the world will not prevent errors if they are not used consistently.(1)
It would be impossible to examine every drug administration in this level of detail, but taking the time to look at processes and listen to caregivers will teach us how to prevent future problems. We can look at every incident report as a signal to identify bigger problems.
Patient Safety Solutions
Engineering for safety allows for creativity. Complex technological solutions include computerized order entry, barcode scanning and smart pumps. While we strive to incorporate safety at every opportunity, these solutions require time and money. Practitioners probably have less complex technology solutions in mind as well, such as special labeling on high-risk medications and tubing,(2) independent double-checks (use an electronic ICU presence if you have it), and preprinted order sets. Numerous examples of similar solutions appear in the literature and in the patient safety section of the Institute for Healthcare Improvement Web site (www.ihi.org). Query your practitioners on what tools would make a given process safer and easier.
Evaluation of high-risk events (near misses) can reveal important safety information when we apply a systematic, analytical approach.(3) It is our willingness to look and listen that creates and reinforces the safety culture in each unit. You can learn about a group effort for improved patient safety in Indianapolis at www.indypatientsafety.org. Larger coalitions also have been successful. In Maryland, a voluntary, state-wide initiative resulted in improved safety scores for many participating hospitals.(4) The Keystone Project in Michigan also has produced significant improvements in patient safety.(5)
High-risk medications are not the only safety concern. Just a few years ago, I thought preventing catheter-related bloodstream infection was an impossible quest. Although we all have processes in place to prevent this condition, the goal may not be achieved if just one of the steps is not followed routinely. I learned that it is possible to prevent these infections, and evaluating and fine-tuning the process produces amazing results.(6)
What we do every day contributes to patient safety. Taking it to the next level through team interaction, evaluation and improvement can achieve some incredible results for our patients. Please make safety your focus. Let’s never see another headline about a patient death caused by a safety violation.
SCCM’s Role
The Society has resources to help your institution improve safety practices at www.LearnICU.org, including the presentation, “Are Your Everyday Drugs Killing Your Patients?”
Patient safety initiatives are supported on a broader scale by the Society of Critical Care Medicine (SCCM) leadership. The Society joined stakeholders and representatives of the Critical Care Societies Collaborative – the American Association of Critical-Care Nurses, the American College of Chest Physicians and the American Thoracic Society – to formulate a research agenda for evaluation of electronic ICU patient monitoring. This conference was funded by an Agency for Healthcare Research and Quality grant. Using telemedicine, clinicians can remotely monitor patients’ vital signs, physiologic status and laboratory studies, intervening if necessary. Remote monitoring and intervention has the potential to improve significantly the quality, safety and efficiency of care. To date, published outcomes related to ICU telemedicine have been varied, but much can be learned through the successes and failures. The conference proceedings will be published as a roadmap for future research. The Society and its critical care partners will continue to seek opportunities to improve the understanding, availability and application of patient safety processes.
References:
1. Rothschild JM, et al. A controlled trial of smart infusion pumps to improve medication safety in critically ill patients. Crit Care Med. 2005;33:533-540.
2. Porat N, et al. Use of colour-coded labels for intravenous high-risk medications and lines to improve patient safety. Qual Saf Health Care. 2009;18:505-509.
3. Habraken MMP, et al. If only…:failed, missed and absent error recovery opportunities in medication errors. Qual Saf Health Care. 2010;19:37-41.
4. Kazandjian VA, et al. Enhancing medication use safety: benefits of learning from your peers. Qual Saf Health Care. 2009;18:331-335.
5. Pronovost PJ, et al. Improving patient safety in intensive care units. J Crit Care. 2008;23:207-221.
6. Pronovost P, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732.
