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Improving the Safety of Heparin Administration by Implementing a Human Factors Process Analysis.


In: Henriksen K, Battles JB, Marks ES, Lewin DI, editors.


Advances in Patient Safety: From Research to Implementation (Volume 3: Implementation Issues). Rockville (MD): Agency for Healthcare Research and Quality (US); 2005 Feb.
Advances in Patient Safety.


Heparin administration errors can have severe consequences for patients. Despite a previous attempt to standardize the heparin administration process through the use of a computerized protocol at a large Midwestern hospital, errors still occurred at unacceptably high rates. A Heparin Error Reduction Workgroup (HERW)—consisting of staff nurses, pharmacists, and a cardiologist—was convened in 2002 to address the issue. The HERW asked human factors consultants to conduct a human factors process analysis of the nursing staff's heparin administration procedures. The consultants observed the work process involving heparin administration in several nursing stations and conducted interview sessions with (1) the physician and pharmacist who developed the heparin protocols; (2) staff pharmacists; (3) nursing administrators; (4) nurse educators; and (5) nurses from cardiovascular nursing stations where heparin is administered extensively, and medical/surgical nursing stations where it is used less frequently. After analyzing the information collected in the interviews and observations, the consultants recommended changes to make the computerized heparin dosing interface more user-friendly, for example, presenting no more than three responses per computer screen to the practitioner, and automatically interconverting English and metric weight and height measurements. The HERW approved and implemented many of the recommendations. The revised heparin dosing computer interface was then tested by a representative sample of nurses and pharmacists from all areas of the hospital. Further modifications were made based on feedback from the participants in the test. A 5-day educational process was then instituted to inform practitioners about the new heparin administration procedure. Following the education, the upgraded computer-driven procedure was implemented hospitalwide. This new procedure has been very well received by the nurses who administer heparin. In the first quarter following implementation of the recommendations, there was an 11.4 percent reduction in the type of heparin errors that resulted in increased monitoring or harm to patients on the cardiovascular nursing stations. In the subsequent quarter (4Q2003), there was a 37.8 percent reduction from 2002 preimplementation baseline data.

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