US heparin overdoses "not preventable" by IT

Accidental overdoses of the blood thinner heparin which were given to 17 infants at a Texas, USA, hospital might not have been avoidable by the adoption of a computer physician order entry system. The error, which follows similar reports in other parts of the country (Marketletters passim), was allegedly made by a pharmacist, but the type of intravenous procedure used would not normally be part of a physician's orders, according to Dennis Tribble, the chairman of the pharmacy-informatics section of the American Society of Health System Pharmacists.

Baxter Healthcare, a leading supplier of heparin in the USA, has already changed the label design on its packaging, making it easier to distinguish between different dosages of the drug. However, a UK-based nursing expert told the Marketletter that the best practice for IV treatments would require two staff members to double-check that the correct drug and amount was administered. This has been cut down to one person in some clinical environments, for example in the UK. In US medical centers where accidental heparin overdoses were given, reports have not confirmed the number of staff required for verifying IV dosages.