Post surgery alert

Regulatory group tells hospitals to adopt strict rules to prevent errors
with blood thinners
Wednesday, September 24, 2008 04:30 CDT

CHICAGO, ILLINOIS -- The regulatory group Joint Commission told hospitals
Wednesday to adopt strict measures to prevent errors involving blood thinners
including heparin - mistakes that have been made nearly 60,000 times and led
to dozens of deaths in recent years.

The Joint Commission issued a safety alert saying hospitals need to adopt
prevention measures that could include bar-coding technology for medicines
or computerized drug orders.

It advised hospitals to more closely monitor patients on these drugs and
make sure that adult-strength heparin is stored nowhere near children's
units.

The alert said 28 deaths are among 32 reports of drug errors involving blood
thinners that it received between 1997 and last year.

"We know that there are many more (deaths) and ... that's the reason for
issuing this alert," said Dr. Mark Chassin, president of the Oakbrook
Terrace, Illinois-based commission.

Recent errors include accidental life-threatening heparin overdoses given to
actor Dennis Quaid's newborn twins at a Los Angeles hospital last November.

In July, 14 babies received accidental heparin overdoses at a hospital in
Corpus Christi, Texas.

Commission investigators will make unannounced visits to make sure hospitals
are adopting strict measures to prevent blood thinner errors, and those who
fail to do so could see their accreditation revoked, Chassin said.

The commission is a private group that sets hospital standards and accredits
most of the nation's hospitals. Accreditation brings prestige and federal
dollars.

A total of 59,316 medication errors involving blood thinners were reported
between 2001 and 2006 to a database run by U.S. Pharmacopeia, a group that
sets drug standards, the alert said. Nearly 3 percent, or roughly 1,700,
resulted in patient harm or death, the commission said.

Blood thinners are particularly tricky to use because too much can cause
hard-to-control bleeding internally and from every body opening; too little
can result in life-threatening blood clots, Chassin said.

Heparin is usually given intravenously. Warfarin, another blood thinner
cited in the alert, is available in pills patients can take at home but can
cause bad reactions when mixed with other medicines.

The recommendations "absolutely" will make a difference and hospitals will
pay attention, said James Conway, senior vice president of the nonprofit
Institute for Healthcare Improvement in Cambridge, Mass.

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On the Net:

Joint Commission: http://www.jointcommission.org

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