This Rapid Response Report alerts all healthcare professionals to the risks of prescribing, dispensing or administering intravenous heparin flush solutions to NHS patients.
These are widely used in healthcare to keep both peripheral and central lines open. Practitioners do not always recognise the risks with their use. Risks are increased if they are not formally prescribed or subject to a patient group direction.
Other problems include confusion with other lookalike products, selecting the wrong medicine when placed in an unlabelled syringe, and errors in calculating and making up dilutions.
The National Reporting and Learning Service has reviewed patient safety incident reports concerning mis-selection of sodium heparin products. It received 28 incident reports between January 2005 and December 2007. It also received eight reports where other medicines including diamorphine, lidocaine and magnesium were mis-selected for heparin flush solution products.
Actions for healthcare organisations include:
- Reviewing local policies to minimise the use of heparin flush solutions in all devices, including complex central venous or arterial catheters. Heparin flushes should not normally be used to flush peripheral intravenous catheters.
- Only administering flush solutions following a prescription or patient group direction.
- Reviewing local policy and procedures to minimise risk when using heparin flush solutions.
- Informing staff about this guidance and revised policy.