Sources of Error in Heparin Therapy of Thromboembolic Disease

Abstract

We observed a series of patients with thromboembolic disease treated intravenously with heparin sodium and monitored by the activated coagulation time (ACT) of whole blood. When patients responded slowly, had dangerous hemorrhage, or had ACTs well outside our target range, we analyzed infusion records to determine actual infusion rates. We found the following sources of error: (1) lack of pump precision, (2) interruption of infusion, (3) errors in making up solutions, and (4) failure of infusion or charting techniques.