| Description |
Anticoagulants are considered a high-alert or a high-risk medication (D'Souza et al., 2019; Johnson et al., 2018; Kindelin et al., 2020; Oertel & Heparin Consensus Group, 2004). This is due to their narrow therapeutic index and the "ability to cause significant patient harm or death" if given in error (Austin et al., 2020). Intravenous (IV) heparin is a common anticoagulant often given for Deep Vein Thrombosis (DVT), pulmonary embolism (PE), Acute Coronary Syndrome (ACS) or atrial fibrillation (D'Souza et al., 2019; Kindelin et al., 2020). If patients' IV heparin infusions are not monitored closely, it can result in the patient becoming subtherapeutic or supratherapeutic leading to the patient potentially developing a clot or bleeding (Johnson et al., 2018). There have been improvements to standards of practice in regards to IV heparin administration over the years. These include transitioning to a nurse-driven nomogram from a provider-driven approach (Shurr et al., 2017), the implementation of the Electronic Medical Record (EMR) (Austin et al., 2020), and the integration of smart infusion pumps (Shurr et al., 2017). Laughner et al. (2020) looked at a hospital that implemented a "process standard work", which was a tool that gave step by step instructions on unfractionated IV heparin infusions, how to adjust doses based on aPTT results, and accurate follow up lab monitoring. Though there was no significant difference between the before and after implementation process, there was a concern for protocol adherence, which was not evaluated well at the time of the study. In the literature, there are many causes that lead to medication errors, especially with a high-risk medication, such as IV heparin. One cause can be due to alert fatigue and poorly managed alert settings (Marwitz et al., 2019). Marwitz et al. (2019) found that only half of respondents actually read and reviewed the action that triggered an alert. Austin et al. (2020) also found that 96% of EMR alerts were ignored. Medication interruptions were another cause for medication errors (Oertel & Heparin Consensus Group, 2004). Even though nurses can't control when their patient is going to travel throughout the hospital, it is important that nurses reduce the number of interruptions as it can compromise heparin's therapeutic effects (Oertel & Heparin Consensus Group, 2004). Lack of communication and staffing shortages also contribute to medication errors (Johnson et al., 2018; Oertel & Heparin Consensus Group, 2004; Sessions et al., 2019). Johnson et al. (2018) found that a lack of communication during nurse-nurse shift report contributed to the heparin errors due to a lack of set guidelines in nursing report and a lack of consistent lab draw times making it difficult for nurses to remember. Oertel and Heparin Consensus Group (2004) reported a survey that was conducted by the National Council of State Boards of Nursing. It reported that 49% of RNs reported to committing a medication error with 70% citing inadequate staffing as the contributor. This caused a lot of moral distress to the nursing staff that committed the error resulting in them questioning their job satisfaction and reducing job retention. Other causes of medical errors Sessions et al. (2019) found included patient-related issues and inadequate policies. All of these factors are barriers to providing safe patient care (Sessions et al., 2019). |
