Changes with heparin labels

As seen in the Consultant Connection November 2014 Issue
NurseAdviseERR July 2014
We recently received a report about a close call involving 30 mL multi-dose vials of heparin containing 1,000 units per mL. These vials were stocked in an automated dispensing cabinet in a hospital’s emergency department. A nurse needed to give a patient a 5,000 unit IV loading dose, but she thought the vials contained 10,000 units per mL. She was confused because she was not familiar with the new heparin labels. The labels now list the total amount of drug per vial on the primary display panel with the amount per mL immediately below in parentheses (Figure 1). The nurse thought she should administer 0.5 mL from the vial, which she believed would yield a 5,000 unit dose. (It would have yielded a 500 unit dose.) Instead, she discussed her concerns with the pharmacist before administering the drug. The pharmacist pointed out the label change on the vial, noting that the concentration was, in fact, 1,000 units per mL.
While we published information about the heparin label changes in our November 2013 newsletter, and also activated a National Alert Network announcement in June 2013 (www.ismp.org/sc?id=249), we feel this information is worth repeating given the recent close call. It is apparent from this report that all nurses may not be aware of the label change. Formerly, only the amount per mL and container volume appeared on the label. Now, the total amount of drug must appear first, with the per mL amount below it. These changes were made in response to ongoing reports of heparin overdoses when individuals believed the amount per mL was the amount in the entire container. Please inform all of your colleagues, including doctors, pharmacists, and nurses, who use heparin about the label change.
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Figure 1. Example of new label style (right) with total amount of heparin per vial, next to older label style (left). Each vial holds the same amount of heparin. All manufacturers of heparin must use the new label style.

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