Preventing Substitution Errors Involving High-Concentration Heparin Products (ISMP Canada‪)‬

As part of a collaborative initiative to understand the patient safety issues related to the use of anticoagulants, ISMP Canada conducted an Anticoagulant Safety Survey of Canadian hospitals in spring 2006. The goal of the survey, the first pan-Canadian survey of its kind, was to gain information on the storage and use of heparin products, the use of venous thromboembolism (VTE) prophylaxis in hospital patients, and the management of patients receiving anticoagulants (ISMP Canada, 2006, p.1). This article highlights the preliminary findings from the anticoagulant survey regarding storage of unfractionated heparin, information from error reporting programs and shares learning from medication incident reports involving the inadvertent administration of high-concentration heparin (excluding infusion pump programming errors). Preliminary survey results: Storage of heparin