Heparin Mixup

Introduction. One of the so-called celebrated cases of medical errors is the case of the twin children of the movie star Dennis Quaids. The image to the right is an example of the heparin vials involved in the case, with one for 10 units/mL, and the other 10,000 units/mL, a  difference of 1000 times in concentration. Similar cases were reported in Indiana, Texas and Montana.(Image credit: ISMP, 2018, Heparin Vials in Two Concentrations [ONLINE]. Available at: https://www.ismp.org/resources/infant-heparin-flush-overdose [Accessed 31 July 2018].) 

From what we learned in the last module on human limitations in cognition, what types of human errors would you expect? We can anticipate confirmation errors: we sometimes see to confirm what we believe. We can also anticipate reading errors: we do not read everything presented to us. Applying these human factors concepts to this case, what would you do to reduce harms to patients? Should we consider enhanced education? Administrative oversight? Triple checks? Keep these questions in mind when you view this video assignment, a news report on the Quaids twin case.

(Want to explore further? Check this post on LinkedIn (Links to an external site.) on poorly designed drug labels.)

Expectations. This is an assigned video and you are required to submit your reflections after watching the video.  Click the video link below to watch. Then click the link “Submit Assignment” ABOVE, to show the submission area. You can write your reflections in a file and then copy and paste, or write directly into the space provided. Do not forget to submit.

Write down your reflection (300 words or less) using these two questions as a guide:

• Are design changes on the vial labeling more effective than educating health professionals to reduce reading errors and prevent patient harms? 
• How would you judge if one intervention is better than another based on what you have learned about human limitations?