Enhancing Heparin Infusion Safety: A Quality Improvement Initiative

Heparin, a critical high-alert medication, plays a pivotal role in the management of thromboembolic events. However, its administration and management, particularly in the inpatient setting at a large hospital in the Intermountain West, was fraught with challenges. We identified opportunities to improve the heparin management process. Methods: This quality improvement (QI) project employed the Plan-Do-Study-Act cycle to address the gaps in heparin management. Interventions included structured interviews and observations to assess the former heparin shift report workflow, the development of a standardized paper shift report tool to enhance Registered Nurse (RN) communication and the analysis of patient safety reports to identify and address medication errors. The interventions aimed to improve the accuracy and efficiency of heparin administration and monitoring processes. Results: The project identified key areas for improvement, including the need for standardized RN shift reports and enhanced communication protocols. A standardized RN shift report tool tailored for heparin infusion handoffs was developed. Conclusions: The standardized RN shift report tool was well-received by the nursing staff, and there was potential for improved patient safety and workflow efficiency. Preliminary findings suggested a positive impact on the accuracy of heparin administration, though further evaluation was necessary to assess the outcomes. Future efforts will focus on implementing and evaluating the long-term effect of these improvements on patient safety and exploring opportunities for broader application in medication management.