In November 2012, the National Alert Network (NAN) reported that the U.S. Pharmacopeial Convention (USP) updated labeling standards for Heparin Sodium Injection, USP and Heparin Lock Flush Solution, USP (including heparin prefilled flush solutions). The labeling changed from dose of drug per ml, to the identification of the total amount of drug per vial. These revised standards were official May, 1, 2013.
Misreading of the label has led to dangerous and deadly heparin overdoses.
Implications for Practice:
Pharmacists, staff nurses, physicians, nurse educators, and risk managers need to have a heightened awareness of the heparin label changes.
Recommended Best Practices to Minimize Patient Risk:
- Computer databases should express drug amounts to be consistent with vial labeling.
- Separate heparin vials and use older vials with older labels first before dispensing the vials with updated labeling.
- Completely transition to newly labeled heparin and discard older vials.
- Place high-alert drug warnings on automated medication dispensers.
- Restrict multi-dose heparin vials.
- Keep unit stock vials as small as possible to limit the potential of heparin overdoses.
- If a heparin bolus is required, consider heparin bolus doses dispensed from a pharmacy.
For more information: http://www.nccmerp.org/pdf/nANAlertJune2013.pdf