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Heparin is undoubtedly a useful medicine in the battle against ill-health. However, besides being used for prophylaxis, heparin is also widely used to flush intravenous peripheral and central lines in an attempt to keep them patent.
Dangers associated with the use of heparin flushes
There is evidence to suggest that heparin flushes are a serious risk to patients without providing any commensurate benefits. For example, at a London hospital, vials containing several doses of the medicine were on two separate occasions administered in their entirety to two different patients. This resulted in the patients receiving 25 000 IU of heparin rather than the intended dose of 5000 IU and requiring medical intervention to remedy the situation. Fortunately neither incident resulted in any long-term harmful effects. However, on another occasion this same error in the same hospital “resulted in death from cerebral haemorrhage”.1
More recently in the UK, four young patients were admitted to an acute trust's day bed unit to undergo diagnostic tests. As young children do not tolerate invasive procedures very well when awake, the tests were to be carried out under general anaesthesia. As part of the procedure the consultant paediatric anaesthetist was to administer a heparin flush. However, owing to human error and systems failures, each child was inadvertently administered 25 000 IU of heparin—that is, a dose 500 times greater than that which had been intended. None of the children involved in these incidents were reported to have experienced any lasting effects. However, the seriousness of these events cannot be overstated. …
This is reprint of a paper that appeared in Quality & Safety in Health Care, April 2009, volume 18, pages 84–5. Reproduced with kind permission of author and publisher.
Competing interests None.
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