Minimise use of heparin flushes, says NPSA
Use of heparin flush solutions in all devices should be minimised following a Rapid
Response Report issued by the National Patient Safety Agency last week. The guidance is relevant to all healthcare professionals who are prescribing, dispensing or administering intravenous flush solutions to NHS patients.
Risks with heparin flushes are not well recognised by practitioners,
says the NPSA, and are increased if they are not formally prescribed
or subject to a patient group direction. Other problems include confusion
with “look-alike” products, mis-selection for other prepared
products when placed in an unlabelled syringe before administration and
errors in calculating and making up dilutions.
The NPSA received 28 reports concerning mis-selection of heparin products
between January 2005 and December 2007. In addition, it received eight
reports where other medicines, including diamorphine, lidocaine and magnesium
were selected instead of heparin.
The report notes that evidence reviewed recently by UK Medicines Information
indicates that there is no advantage to using heparin flushes over normal
saline for maintaining peripheral intravenous catheters. The evidence
for central venous or arterial catheters is less clear and specific policies
may be required locally depending on the individual devices used, it
says.
The NPSA therefore recommends that:
• Organisations should review local policies to minimise the use of
heparin flush solutions in all devices, including complex central venous
or arterial catheters
• All flush solutions should only be administered following a prescription
or patient group direction
• Local policy and procedures should be reviewed to ensure risk is minimised
• Organisations should ensure that all relevant staff are aware of this
guidance and revised policies
The deadline for action to be completed is 24 July 2008. The report
is available online |
The
Pharmaceutical Journal
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