Baxter and FDA warned of heparin risk in 2007

This is an excerpt from the "Important Medi-cation Safety Alert" that was issued on Feb. 6, 2007, by Baxter Healthcare Corp. and the Food and Drug Administration involving Heparin Sodium Injection 10,000 units/mL and HEP-LOCK U/P 10 units/mL:

The currently marketed 1 mL vials of Heparin Sodium Injection 10,000 units/mL and the HEP-LOCK U/P 10 units/mL use shades of blue as the prominent background color on their labels. Healthcare professionals should be reminded to:

  • Never rely on color as a sole indicator to differentiate product identity.
  • Always carefully read the product label to verify that the correct product name and strength have been selected.
  • Always carefully review both the drug name and dose on the label before dispensing and administering these products.
  • Double-check your inventory as soon as possible, to ensure that there is no mix-up of the products.
  • Notify all staff of the potential for errors in dispensing and administering these products. It is advised that you provide color photographs to staff to assist in their understanding of the product similarities.

The alert goes on to say that providers should "ensure that all staff responsible for the dispensing and administration of Heparin Sodium Injection and HEP-LOCK U/P products are aware of these medication errors and that the staff are familiar with your policies and procedures."

Baxter says risk managers with further questions can contact the company at (800) 262-3784. The full text of the alert, including photographs of the products, is available at the FDA web site at www.fda.gov. Enter "heparin medication safety alert" in the search box at the upper left of the home page, and then click on "IMPORTANT MEDICATION SAFETY ALERT."