Heparin Error

Updated:   Published

I made my first med error as a new grad; I flushed a peripheral IV with heparin flush. Didn't realize my error until shift change, 9 hours later. Patient was okay. Told my preceptor. I feel absolutely horrible and like I made a huge mistake and could have really hurt someone. How do I feel better about this? I keep stressing over the effects this could have had on my patient. 

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Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.

You feel better by learning a few things.

1) Heparin flush is usually 10 units/cc. How many units per hour do people getting heparinized usually get? Yes, hundreds. So no, no harm done except under VERY rare and specific circumstances.

2) Bazillions of people make that same error, and yet hospitals continue to stock saline flushes and heparin flushes even though the research shows that routine NS is just as effective at keeping a PIV open. Perhaps you could look up the literature on that and advocate for a change in policy so nobody would feel bad about this again.

3) A true heparin OD is easily reversed. They do this routinely when people are heparinized for hemodialysis so the artificial kidney doesn't clot off, on cardiopulmonary bypass, and other circumstances. 

You have learned a very valuable lesson in reading the labels, and you had the great good luck to do it when it wasn't even clinically significant. YOu reported it, and all is OK. You'll never make that mistake again, will you? So deep breath, and go forth and sin no more.

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1 hour ago, Hannahbanana said:

... YOu reported it, and all is OK. You'll never make that mistake again, will you? So deep breath, and go forth and sin no more.

I can't improve on that message.  Take a breath OP, learn from this and you will be fine!

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For many many years we flushed peripheral it's with heparin flushes.  I have been to a few places that still do that.

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Specializes in Physiology, CM, consulting, nsg edu, LNC, COB.

oh, I know. I used them for years. research doesn't support it though.

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How was the error recognized? Did you have to the scan the Heparin flush?

 For what it's worth, back in my day... we flushed all IV locks with Heparin.  I had a little difficulty switching to the saline protocol.

 

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What I was going to say about heparin flushes has already been said. Then I realized that's not actually the extent of it from my perspective.

2 hours ago, rnash679 said:

I feel absolutely horrible and like I made a huge mistake and could have really hurt someone.

Not looking at and not knowing what's in our hands is always going to involve the potential to really hurt someone. Even if, this time, it happened to be a heparin flush.

I've made a couple of completely harmless errors (weirdly, they both actually improved the patients' overall conditions). In retrospect I think it was very good that 1) there was some comfort involved in the fact that no one had been hurt but 2) that I was still completely appropriately scared [blank]less by the behavior of mine that led to the error (the one in particular completely involved not being conscientious in the moment, etc.)

I don't want people to be so freaked out (in a negative way) that they're more likely to make subsequent errors due to the distraction of anxiety, but we also realistically can't afford to minimize the act that happened.

I say "be comforted" but also "make immediate changes."

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There was actually an order for a heparin flush for the line; this did not specify "what type" of line. I pulled the heparin and flushed the peripheral line per the MAR. However, as I was going over the MAR at the end of shift to ensure nothing was missed, I had a feeling a peripheral IV was not to be flushed with hep. I did some research, realized it is just for PICC/port and notified my preceptor. So essentially, I had an order, however I did not follow the order properly per protocol. I will never make that mistake again. 

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Specializes in Dialysis.
41 minutes ago, rnash679 said:

There was actually an order for a heparin flush for the line; this did not specify "what type" of line. I pulled the heparin and flushed the peripheral line per the MAR. However, as I was going over the MAR at the end of shift to ensure nothing was missed, I had a feeling a peripheral IV was not to be flushed with hep. I did some research, realized it is just for PICC/port and notified my preceptor. So essentially, I had an order, however I did not follow the order properly per protocol. I will never make that mistake again. 

You learned and that is the most important lesson going forward

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Specializes in oncology.
On 11/9/2020 at 5:05 PM, Kyrshamarks said:

For many many years we flushed peripheral it's with heparin flushes.  I have been to a few places that still do that.

In the late 70s. early 80s I worked at a place that used 100 Units/ml for peripheral locks. The IV team boasted of their impressive stats for keeping lines open! It all came to a head for me when I turned a very ill, very old patient to her other side and saw a bruise on her cheek. When we calculated the amount of flush she received it was clear that she was receiving a substantial dose.

On 11/9/2020 at 6:41 PM, rnash679 said:

However, as I was going over the MAR at the end of shift to ensure nothing was missed, I had a feeling a peripheral IV was not to be flushed with hep. I did some research, realized it is just for PICC/port and notified my preceptor.

Heparin half life is 6 hours so the patient had probably metabolized it by then with no injurious action. 

10 years ago Dennis Quaid's twins were victims of a horrible med error. The publicity that came out of it really pressed home the need to keep heparin and saline flushes entirely seperate when stored and heparin packaging was redesigned to warn the pharmacist, pharmacy tech LPN and RN in a very conspicuous way and I do not think that heparin came in a prefilled syrience (I amy be wrong on that).

I know your error did not involve mistaking one solution for the other.

Here is the story of Quaid's twins:

https://virginiabeach.legalexaminer.com/health/medical-malpractice/preventable-medical-malpractice-revisiting-the-dennis-quaid-medicationhospital-error-case/

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No worries, us old timey nurses remember when it was routine practice to flush peripheral IVs with heparin. Don't be so hard on yourself.

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I didn’t know people flushed PICC lines with heparin unless there is an occlusion. But back in the day, PIVs were flushed with heparin.  
 

Always double check your med orders before giving them.  And I’m sure you will now.  

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