Understanding and Improving Heparin Administration

At a 400-bed teaching hospital in the Mountain West, unfractionated heparin administration continues to be a source of medication errors despite attempts to mitigate the inherent risks and improve education for all healthcare providers involved. Other institutions have completed quality improvement (QI) projects surrounding heparin administration, which yielded mixed results in improving protocol adherence (Harder et al., 2005; Laughner et al., 2019). According to data provided by the Heparin Improvement Work Group (HIWG) (2021), since the Go-Live of the new heparin protocol and the education that accompanied its rollout in 2018, self-reported safety events related to heparin have increased by 60%. These data further demonstrate that, in the most recent six months of information, nearly half of errors are connected to a knowledge gap, with many nursing-related errors attributed to lack of protocol compliance and understanding. Other sources of error include: transitions of care, ordering, global processes, mechanical failures, weight issues, and medication distribution. This reflects a pattern of unsafe medication practices and knowledge gap that may contribute to worse patient outcomes. [This QI project] is intended to reduce errors related to heparin administration to improve patient safety. The objectives are as follows: Conduct a gap analysis to discover sources of error; Create a usable tool to support nursing workflow related to identified challenges; Recommend updates to educational practices and electronic health record (EHR) surrounding continuous intravenous administration of heparin.