Quality Improvement Project to Enhance Heparin Safety in Patients with Haemodialysis in China

© Author(s) (or their employer(s)) 2022. Reuse permitted under CC BYNC. No commercial reuse. See rights and permissions. Published by BMJ. INTRODUCTION Maintaining safety in a haemodialysis (HD) unit is paramount. Lowmolecularweight heparin (LMWH) is commonly used as an anticoagulant to prevent clot forming in the extracorporeal circuits (ECCs). 3 Incorrect dosages of anticoagulant may bring risks to patients with HD. Presently, most HD units determine their own dosages of LMWH according to their own experience, and guided by clinical efficacy. Monitoring of lowrange activated clotting time (ACTLR) and antiXa activity is rarely undertaken or available. Chinese national standard operational procedure (SOP) for HD has suggested no specific LMWH regimen, leaving it to the discretion of individual HD units. Most Chinese dialysis units appear to have an array of heparin regimens of their own. Our HD unit has been built within a public comprehensive hospital in the south of China and was awarded Australian Council of Health and Safety accreditation. It has 50 dialysis stations where 200 patients with chronic HD are dialysed in 3 shifts. Typically, it gives a single bolus intravenous injection of dalteparin at 60 IU per kg body weight before dialysis. The measurement of ACTLR or antiXa activity is not available in our hospital. The bolus dosage would simply be increased by 250 IU if there were signs of clot, or decreased by 250 IU if bleeding was prolonging. In the present incident, 12 patients with HD developed clot in their ECCs almost simultaneously about an hour into dialysis. The ECCs were replaced swiftly so that all the dialysis treatments were completed as scheduled and the patients were safe. The hospital’s incident management team (IMT) was notified immediately. A dalteparin admixture error was suspected. Quality improvement (QI) meetings were held and team members brainstormed for possible root causes and identified possible solutions. METHODS Following on the heels of the incident, a QI meeting was held and members of IMT, Pharmacy Department, Clinical Service Department and Nursing Department were invited to participate. The routine dalteparin process from prescription to admixture, check and final administration was reconstructed and scrutinised item by item by all the participants with fishbone diagram and 5whys as the guide. The fishbone diagram in figure 1 lists our deficiencies in terms of people, process and environment as we found them. The 5whys technique drives us to keep asking why. Ideas generated by both tools helped immeasurably our QI team in its search for root causes of the dalteparin medication errors and their possible resolutions in its brainstorming meetings.