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A staff nurse was helping an I.V. team nurse flush a multilumen central venous catheter. The catheter had been inserted 3 days earlier because the doctor wanted to start the patient on total parenteral nutrition (TPN), but he hadn't ordered it yet.
According to hospital procedure, the I.V. nurse was supposed to flush each port of the catheter with 10 ml of normal saline solution, followed by 1.5 to 2 ml of heparin flush solution, 100 units/ml. The staff nurse mistakenly picked up a vial of heparin, 10,000 units/ml. Without checking the label, she prepared the heparin flush solutions to be used at the three ports. The patient received 60,000 units of heparin and later began bleeding from his nose, urinary tract, and bowel.
Obviously, if either nurse had read the heparin label, this serious error could have been prevented. But we should consider other factors. Why did the nurse even have to draw up the heparin? Several manufacturers package heparin flush solutions in syringes in various strengths. The nurse need only have reached for three ready-to-use syringes.
Also, why was heparin available in the unit's stock at 10,000 units/ml? That concentration should be issued by the pharmacy only for specific patients.
Finally, why was a central venous line in place if it wasn't being used? If it hadn't been ordered prematurely, the error would never have occurred.