Latonia Wilson is nurse manager for a busy 20-bed telemetry unit.
In addition to providing postsurgical care for cardiac patients, nurses also prepare patients for cardiac catheterization lab procedures. Latonia’s staff includes eight new graduate nurses, almost half of her nursing staff. The new nurses have attended most of the required nursing orientation for the hospital.
Three times in one month, telemetry unit patients who had orders for heparin drips were administered heparin flush instead. Premixed IV bags for heparin drips as well as heparin flush for indwelling arterial catheters are stocked on the IV solutions cart in the medication room. While no adverse patient outcomes had been re- ported, procedures have been delayed.
Geena Donati is a graduate nurse on the telem- etry unit. Recently, she took a bag of heparin drip from the IV cart and started to attach it to the IV tubing. She noticed that the label stated heparin flush in- stead of heparin. Upon returning to the med room, she checked the heparin drip bin and found heparin flush bags mixed in with the heparin drip. The phar- macy technician came into the med room and began stocking the IV cart. Geena noticed that the pharmacy technician put extra heparin drip bags in the heparin flush bin. She questioned the pharmacy technician and he told Geena that since the unit used a lot of heparin
solution, he had started bringing extra to decrease his trips to the unit.
Geena met with Latonia later during her shift. She told her manager about the extra heparin bags be- ing mixed into the wrong bins. Latonia asked Geena if she would be interested in working with two other RNs on the unit to develop new procedures to decrease heparin medication errors. Geena and the task force worked with the pharmacy department to change the label color for heparin drip and heparin flush solutions, physically separated the bins on the IV cart onto differ- ent shelves, and provided a short educational segment at the monthly staff meeting. Since the new procedures were developed, no further heparin errors have oc- curred on the telemetry unit.