A nurse titrated a heparin infusion based on the baseline PTT instead of the 6-hour PTT, leading to a medication error due to confusion about which lab value to use.
Current protocols require manual differentiation between baseline and titration PTT values, which can be confusing, especially when returning from leave or when protocols are not fresh in memory. No automated system clearly flags which value to use, leading to potential errors.
Workarounds Described
- Manually reviewing protocol to determine which PTT to use
Implied Software Gaps
- Clinical decision support tool that automatically flags the correct lab value for titration and prevents basal titration errors
HeparinGuard
HeparinGuard is a clinical decision support tool that integrates with EHRs to clearly identify baseline vs. titration lab values and provides real-time, protocol-driven titration guidance. It eliminates confusion by automatically flagging the correct PTT for titration and alerts nurses if they attempt to adjust based on baseline. The app ensures safety and reduces medication errors.
- Automatic identification and labeling of baseline vs. titration PTT results
- Real-time heparin titration calculator based on hospital protocol
- Visual alerts when attempting to titrate using the wrong lab value
- Audit trail and documentation of titration decisions for incident review
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