A patient with acute thrombus—a blood clot in a vein or artery—was being transferred from an emergency department at a small outlying facility (“transferring facility”) to the intensive care unit (ICU) at a larger hospital (“receiving facility”). To treat the thrombus, the transferring facility had started the patient on heparin, a high-alert medication which decreases blood clotting, at a rate of 2100 units/hour. A practitioner at the receiving facility needed to convert this to the hospital’s acute thrombus heparin protocol and thought 2100 units/hour equated to 42 mL/hour. However, when they contacted the transferring facility for assistance, the pharmacist there clarified that it actually should be 21 mL/hour—because the transferring facility’s heparin bags had a concentration of 50 units/mL while the receiving facility carried bags with a heparin concentration of 100 units/mL. The pharmacist at the transferring facility called the ICU nurse with instructions to replace the 50 units/mL bag with a 100 units/mL bag and make sure the pump was set at a rate of 21 mL/hour—avoiding accidentally giving the patient a double dose of the medication because of these differing concentrations. Since the incident, the pharmacist has been working with outlying facilities to change their processes, with an eye to mitigating the safety risk of community hospitals using a different concentration of heparin infusion from the network, and emphasizing the importance of evaluation of medication reconciliation upon transfer due to differing dose and medication preparation practices between facilities.​

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