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Potentially Lethal Heparin Dosing Errors in Infants

Some Babies may have Received up to 100 Times the Appropriate Dose

The FDA released information today from the Institute for Safe Medication Practices (ISMP), which states that "serious dosing errors continue to occur when heparin is administered to neonates". The ISMP cites a recent incident in Texas where 17 infants in a neonate intensive care unit were overdosed with heparin, some, the ISMP suggests, could have received as much as 100 times more drug than intended.

The ISMP cites 2 problems they believe lead to heparin dosing errors, one being calculation errors resulting from unfamiliar concentrations of the drug, and the other being the absence of a standard dosing protocol for heparin use in venous and arterial lines in infants.

The ISMP goes on to say that they have in the past provided several suggestions to reduce the likelihood of these errors being made.

DEC-01-08: More Heparin Dosing Errors with Neonates [FDA: MORE HEPARIN DOSING ERRORS IN INFANTS]

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