title: Sources of error in heparin therapy of thromboembolic disease.
abstract: We observed a series of patients with thromboembolic disease treated intravenously with heparin sodium and monitored by the activated coagulation time (ACT) of whole blood. When patients responded slowly, had dangerous hemorrhage, or had ACTs well outside our target range, we analyzed infusion records to determine actual infusion rates. We found the following sources of error: (1) lack of pump precision, (2) interruption of infusion, (3) errors in making up solutions, and (4) failure of infusion or charting techniques.
mesh_terms: D000328:Adult; D000368:Aged; D004305:Dose-Response Relationship, Drug; D005260:Female; D006493:Heparin / Q000009:adverse effects / Q000627:therapeutic use*; D006801:Humans; D007263:Infusions, Parenteral; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000188:drug therapy; D012771:Shock, Hemorrhagic / Q000139:chemically induced; D013923:Thromboembolism / Q000188:drug therapy*; D013924:Thrombophlebitis / Q000188:drug therapy; D014914:Whole Blood Coagulation Time
chemical_list: D006493:Heparin