Qi Presentation Heparin Administration
Qi Presentation Heparin Administration
Project -
Heparin Administration
Dennis Quaids Story
Effect =
Pyxis withdrawal Twins
received
Similar overdose of
packaging of heparin
Hep-Lock different doses
Machines Materials
Root Cause Analysis
Look-alike labels and
Nurse negligence in Twins receiving two
following six rights of LED TO..
overdoses of
medication
administration Heparin in an 8 hour
period
Identical Labels: Both 10 units and 10,000 units of Heparin come in 1 ml vials with similar labels.
Negligence of pharmacy technicians: Two pharmacy technicians delivered 100 counts of 1 ml vials
containing adult dosage of Heparin 10,000 units/ml instead of pediatric dosage 10 units/ml.
Negligence of nurses: Failure to check the dosage by nurses during medication administration.
Mistake committed twice as two adult doses given at 8 hour intervals.
Absence of backup system: No double checking or computer scanning to pick up human errors.
Cost of implementing
Patient safety change
technology
Nursing safety med labeling
training hours
Hospital protection
from lawsuits, Nursing resistance to 2
negligence claims nurse check, additional
training, time for med
administration