An organization reported several heparin infusion events over a year, which prompted several process changes in the electronic health record with the acknowledgement of orders, views within the medication administration record, and labeling of intravenous lines. These events and subsequent changes also led to greater awareness around management of heparin infusions within the organization, as well as more emphasis on hourly rounding to ensure patient safety. As a result, staff was better equipped to recognize problems as they are happening and act quickly to prevent patient harm.
As just one example of the positive impact of reporting adverse events: A patient arrived from the emergency department where a heparin infusion had been initiated. The nurse receiving the patient from the ED checked the infusion pump to make sure that all the settings were correct. Thirty minutes later, she noticed that the 500 mL bag of heparin only had 100 mL remaining; as the infusion had only been running for about 60 minutes, she realized that something was wrong and that the patient had received more heparin than ordered. She called the charge nurse in to look at the pump. The charge nurse immediately stopped the infusion, removed the pump from service, placed an order for a stat partial thromboplastin time (PTT, a blood test to see how long it takes for the blood to clot), notified the night hospitalist, and called the nursing supervisor. They also brought the adverse event to the attention of the nursing director on-call and the patient safety officer.
Ultimately, an investigation of the event revealed a broken hinge inside the pump had caused it to malfunction and alternate between free flow and a regulated drip rate. Because the harsh chemicals used to clean the pumps make the plastic hinges brittle over time, the facility educated and trained staff to look for potential defects, such as small hairline cracks that typically precede this type of break. Any pumps they identify with these cracks are removed from service before the hinge breaks, and the hinge is repaired for the pump is placed back into use.
