Preventing substitution errors involving high-concentration heparin products.

Critical care practitioners routinely administer heparin for various indications (e.g., treatment of acute coronary syndrome, venous thromboembolism prophylaxis, line maintenance) and by various routes (e.g., intravenously, subcutaneously). Knowledge of reported incidents involving high-concentration heparin products can increase practitioner awareness of risks for error-induced injury associated with storage and administration of anticoagulants, such as heparin. Substitution errors leading to administration of an incorrect dose of unfractionated heparin are highlighted and suggestions for system-based error prevention strategies are provided.