Dealing honestly with an honest mistake.

Area of Science:

• Vascular Medicine
• Patient Safety
• Pharmacology

Background:

• A 70-year-old female presented with symptomatic left iliofemoral deep vein thrombosis (DVT).
• Initial treatment involved percutaneous mechanical thrombectomy and thrombolysis, followed by stent placement for identified left iliac vein stenosis.
• Heparin infusion was initiated post-procedure for anticoagulation management.

Discussion:

• A significant medication error occurred where the prescribed heparin dose of 250 U/h was mistakenly documented and administered as 2500 U/h.
• The overdose was detected the following morning due to a significantly elevated partial thromboplastin time (>300 seconds).
• Despite the tenfold heparin overdose, the patient experienced no discernible adverse events, prompting a review of the incident by nursing, residents, and risk management.

Key Insights:

• Accidental heparin overdose can occur due to documentation and administration errors.
• Close patient monitoring, including laboratory tests like partial thromboplastin time, is crucial for detecting heparin overdose.
• The absence of adverse events in this case may be attributed to prompt detection and intervention, as well as individual patient factors.

Outlook:

• This case underscores the critical need for robust protocols in medication administration, including double-checking doses and utilizing barcode scanning systems.
• Further investigation into the specific circumstances of the error is warranted to prevent recurrence.
• Emphasis on clear communication between healthcare providers and meticulous attention to detail during medication management is essential for ensuring patient safety in vascular interventions.