Heparin: Improving Treatment and Reducing Risk of ... - CareFusion

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HEPARIN:IMPROVING TREATMENT AND Reducing Risk of Harm Clinical, Laboratory and Safety Challenges T he short-acting, reversible anticoagulant heparin is widely used in hospitalized patients to prevent the development or extension of potentially life-threatening blood clots. However, numerous issues make the use of this high-risk agent particularly challenging and errorprone. As shown by media reports of heparin-related infant deaths and injury in Indiana, California, and Texas, heparin-related medication errors can have devastating impact on patients, families, staff, and the reputation of a healthcare institution and its leadership. Safe and effective use of heparin requires maintaining a delicate balance—dosing low enough to minimize the risk of bleeding, yet high enough to treat or prevent thrombosis. Achieving a therapeutic level of heparin within 24 hours significantly reduces the risk for recurrent venous thromboembolism (VTE) (Raschke et al., 1993; Hull et al., 1997; Anand et al., 1996; Anand et al., 1999). However, non-protocol-driven practice achieves this outcome only 40% of the time (Wheeler et al., 1988). By William E. Dager, PharmD, FCSHP Robert C. Gosselin, CLS Robert Raschke, MD, MS Tim Vanderveen, PharmD, MS Image Courtesy of Cardinal Health 20 Patient Safety & Quality Healthcare ■ January/February 2009 www.psqh.com
Medication errors involving unfractionated heparin (UFH) are among the most common and serious in clinical practice. More than 17,000 heparin-related medication errors were reported to the U.S. Pharmacopoeia (USP) MEDMARX from 2003 to 2007; 556 of these resulted in harm to patients, including seven deaths (Santell, 2008). An expert advisory panel of The Joint Commission (TJC) recognized that “anticoagulation is a high-risk treatment which commonly leads to adverse drug events because of the complexity of dosing, monitoring and patient compliance” and that “the use of standardized practices can reduce the risk of adverse drug events.” In 2008 TJC issued National Patient Safety Goal 3E (NPSG 3E) to “Reduce the risk of harm associated with the use of anticoagulant therapy.” Hospitals were required to be fully compliant with this goal by January 1, 2009 (TJC NPSG, 2008). Key clinical, laboratory, and safety issues surrounding heparin were addressed in a nationwide webcast on “Improving Heparin Safety,” hosted by the Center for Safety and Clinical Excellence on July 11, 2008. In this article, we summarize important information and recommendations, focusing on the three stages of heparin use that account for 67% of heparinrelated errors—dosing, monitoring and administration (Santell, 2008). Dosing Significant errors in dosing heparin and interpreting reported aPTT values can result from unnecessary variation in physician practice. Standardized protocols for dosing heparin can help reduce such variability. Although physicians sometimes are perceived as being resistant to change, in fact they are more resistant to having change mandated. For this reason, prescribers need to participate in the development and adoption of heparin-related standards, guidelines or protocols. The Deep Vein Thrombosis Prevention program at the University of California, San Diego Medical Center used a multidisciplinary consensus-building process to develop and implement a standardized, physician-friendly, risk-assessment process and VTE-prevention order set. Results showed that appropriate VTE prophylaxis increased from 55% to over 95% of patients and was accompanied by a documented decrease in thromboembolic events (Peterson et al., 2008). Approaches to initiating heparin infusion to reach targets were also reviewed. A study by Raschke et al. showed that compared to a standard, “one-size-fitsall,” initial heparin dosing scheme, a weight-based protocol increased the percent of patients within the therapeutic range within 24 hours from 77% to 97% (p=0.002) and significantly reduced the risk of recurrent venous thromboembolism (RR 0.2, p=0.02). The incidence of bleeding complications was the same in both groups, despite more aggressive dosing in the weight-based group (Raschke et al., 1993). A subsequent study showed that improvements were maintained over a 5-year period with a nearly 95% protocol implementation rate. Initial heparin infusion rates increased from 1,185 to 1,420 units/hour (p
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