August 30, 2016: Accidental Intravenous Infusion of a Heparinized Irrigation in the Operating Room
ISMP Canada received 2 reports describing similar incidents involving the inadvertent intravenous (IV) infusion of a heparinized lactated Ringer's solution intended for topical irrigation. These cases are shared to alert practitioners about this potential hazard and to raise awareness among healthcare providers of the prevalence of this type of wrong-route incident and the harm that can result. Strategies are proposed to optimize the safety of procedures for the preparation, storage, and intraoperative use of irrigation fluids, especially those containing the high-alert medication heparin. Read more ...
