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Getting Started with Storage Safeguards to Minimize the Risk of Harm with Unfractionated Heparin

ISMP Canada, as the lead of the Medication Safety Support Service (MSSS) in Ontario and with support from the Ontario Ministry of Health and Long Term Care is launching its third medication safety initiative.

Why Heparin?

  • Heparin is one of the top five medications reported to cause harm as a consequence of medication error.[1]
  • Three neonate deaths occurred in the United States in 2006 from the inadvertent use of high concentration heparin solution.[2]
  • ISMP Canada has received reports and reviewed cases of patient harm related to heparin in 3 separate bulletins.[3]
  • The Canadian 2006 National Anticoagulant Safety Survey preliminary findings indicate:[4]
    • lack of safeguards in hospitals for heparin use and
    • vials of high-dose heparin are widely available in patient care areas in many hospitals across the country.

Heparin Resource Kit

ISMP Canada has compiled a Heparin Resource Kit available for $80 CAD (including taxes and shipping for Canadian orders).

To order, please download and print the Order Form

Summary of Recommendations To Minimize Risk of Harm with Unfractionated Heparin

Additional Resources

  1. Institute for Safe Medication Practices Canada. Top 10 Drugs Reported as Causing Harm through Medication Error. ISMP Canada Safety Bulletin. 2006; January.
  2. Institute for Safe Medication Practice. Three neonates die from heparin overdoses. ISMP Medication Safety Alert! Nurse Advise-ERR 2006;4(10)
  3. Available at
  4. Institute for Safe Medication Practices Canada. Canadian Hospital Anticoagulant Safety Survey 2006
  5. Actor Dennis Quaid's newborn twins nearly died when they were mistakenly given a drug overdose.


Medication Safety Support Service (MSSS) Advisory Group Organizations
  • Ontario Ministry of Health and Long-Term Care
  • Canadian Society of Hospital Pharmacists - Ontario Branch
  • Ontario Hospital Association
  • College of Physicians and Surgeons of Ontario
  • Ontario Medical Association
  • Ontario College of Pharmacists
  • Institute for Safe Medication Practices Canada
  • Registered Nurses Association of Ontario
  • College of Nurses of Ontario
  • Ontario Pharmacists’ Association


The Ontario MSSS is a Collaborative Medication Safety Initiative of ISMP Canada, the Ontario Hospital Association and the Ontario Ministry of Health and Long-Term Care.