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A patient hospitalized with deep vein thrombosis developed a pleural effusion. The surgeon performed a thoracentesis, draining 1,400 ml of blood-tinged fluid. He then wrote an order to resume the patient's heparin drip at the previous rate-1000 units/ hour.
The patient's nurse called in the order and the pharmacist sent a bag to the unit, already mixed and labeled. The nurse quickly hung the bag and set the correct infusion rate.
When the night nurse came on duty a few hours later, sne was puzzled to see that the patient's I.V. bag contained 20,000 unit of heparin in 500 m1 of D5 W. She recalled that the concentration the night before had been 20,000 units in 1,000 ml.
She called the surgeon. He made it clear that he wanted the same concentration as before. Following his orders, the nurse obtained the correct concentration and started the infusion at a lower rate. The patient's partial thromboplastin time was high, as expected, but it dropped to a normal level within a few hours.
Three people contributed to this potentially fatal error. The surgeon failed to specify the concentration in his order. The pharmacist filled the order even though it was incomplete. And the nurse forgot to check the concentration on the label.
This error could have been prevented if these practitioners had been more careful. Better yet, if the hospital had established a standard concentration for heparin (and all critical care drug infusions), only the number of units per hour would have to be ordered. Such a practice is an excellent way to decrease errors.