Heparin infusion errors related to Units/kg/hr vs Units/hr

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Allison M Goodell
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Joined: 08/10/2022 - 15:04
Heparin infusion errors related to Units/kg/hr vs Units/hr

Hello, at our facility we utilize Heparin infusions for: therapeutic anticoagulation, Impella purge solutions (but may be changing soon), as well as a continuous infusion after a peripheral revascularization procedure. The first two infusions are run in doses of units/kg/hr, requiring a patient weight to be entered into the smart pump. The last type of infusion is ordered as a continuous, non-titrated infusion of a set dose of units/hr. We switched to the BBraun Infusomat Space LVP in February, and since then, have had multiple errors related to nursing choosing the wrong heparin entry. Despite using tall man lettering, warnings about dosing, and 2 nurse independent double check, we have had nurses choose the units/hour dosing, and severely underdosing patients. Unfortunately, this particular pump only has a "Soft" lower limit warning, so that the nurse can override the alert that the dose they chose is less than the suggested dose. We think that a HARD lower limit setting saved us with our previous pumps (Baxter). WE have tried more education, discussion at meetings, etc., but realize we have to come up with a better way to separate these in our pump library. Heparin WT based (units/kg/hr) and Heparin NON wt based (units/hr) doesn't seem to work. Has anyone else encountered this issue? Any suggestions??? Thank you in advance, Allison.