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Cases & Commentaries
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Andrew S. Dunn, MD; April 2010
An elderly woman with a history of mitral valve replacement with a mechanical prosthesis was admitted to the hospital for evaluation of abdominal pain. Although an order was written to stop her blood thinner and restart it 48 hours after the procedure, the medication was not restarted.
Daner WE, Gosselin RC, Raschke R, Vanderveen T. Patient Saf Qual Healthcare. January/February 2009;6:20-25.
This article explains safety challenges commonly associated with heparin, a high-alert medication, and outlines how hospitals and clinicians can prevent these errors.
Journal Article > Study
Minimizing errors of omission: Behavioural rEenforcement of Heparin to Avert Venous Emboli: The BEHAVE Study.
McMullin J, Cook D, Griffith L, et al. Crit Care Med. 2006;34:694-699.
The investigators implemented an evidenced-based thromboprophylaxis guideline for medical-surgical intensive care unit patients and found that it significantly altered heparin prescribing behaviors.