By Jonathan D. Rockoff , Sun reporter|May 15, 2008
WASHINGTON — WASHINGTON -- Efforts to make the blood thinner heparin safer - and to replace supplies that were depleted by a major recall this year - have meant unintended and fresh safety concerns for hospitals, heart clinics and dialysis centers that use it.
The drug, a staple of medical care prescribed tens of millions of times a year, was recalled in February after contamination during production in China led to as many as 81 deaths in the United States. Its leading maker, Baxter International Inc., has suspended manufacture of most of its heparin products.
The resulting shortage of heparin - the least expensive and most commonly used drug of its type - means heparin from new suppliers is arriving in different quantities and strengths than medical staffs are accustomed to, and pharmacists and others worry that patients may be vulnerable to receiving improper doses.
Even before the drug's recall, proper administration was a major concern. Heparin is one of the five drugs most commonly associated with errors in hospitals, an issue publicly highlighted last year when the actor Dennis Quaid's newborn twins were mistakenly given 1,000 times the intended dosage.
Neither the Food and Drug Administration nor the private Institute for Safe Medication Practices has received reports of medication errors since the recall, but some medical centers are establishing extra precautions.
"I would be very concerned," said Michael Cohen, president of the Institute for Safe Medication Practices near Philadelphia, which is planning to warn about the higher risk of medication error in the next newsletter it sends to the country's 6,000 hospitals. "I wouldn't be surprised if it has already happened."
The problem, pharmacists and others say, is that doctors and nurses may be unfamiliar with new packaging for heparin and could easily give a patient a more potent dose than intended. Unlike the single-dose products typically distributed by Baxter, many of the vials now contain larger or more potent quantities.
"It can lead to dosing errors ... that could harm the patient," said John R. DiBona, director of pharmacy at LifeBridge Health, the parent company of Northwest and Sinai hospitals in the Baltimore area.
At Northwest and Sinai hospitals, DiBona said, pharmacists have taken several steps to prevent medication errors, such as reminding nurses to draw the drug from a vial instead of using a pre-filled syringe. The hospitals have removed the syringes so nurses won't make a mistake while switching between two different products.
