Why did the supervising resident fail to report heparin (Heparin) infiltration, which caused arm swelling in a patient being treated for pulmonary embolism (PE), despite a similar incident previously resulting in disciplinary action against the nurse?

From the Guidelines

The supervising resident's failure to report heparin infiltration was a critical error that prioritized avoiding consequences for the nurse over patient safety and proper medical documentation. This decision is particularly concerning given the potential complications of heparin therapy, including heparin-induced thrombocytopenia (HIT), a life-threatening immunological complication that can occur in patients exposed to heparin 1. The incidence of HIT ranges from 1 to 3% in patients exposed to unfractionated heparin and is about 1% in patients receiving low molecular weight heparin (LMWH) 1. Key factors that may influence the frequency of HIT include heparin type, patient type, and sex, highlighting the need for vigilant monitoring of platelet counts in patients treated with heparin 1. Some important points to consider in this scenario include:

• The importance of reporting adverse events like medication infiltration to ensure patient safety and facilitate quality improvement efforts
• The potential consequences of heparin infiltration, including tissue damage, pain, and swelling, which require prompt intervention
• The need for healthcare facilities to prioritize accurate incident reporting to identify systemic issues and implement safety measures
• The problematic culture that can develop when avoiding conflict is prioritized over patient safety and proper medical documentation. Given the potential risks associated with heparin therapy, including HIT, and the importance of incident reporting in maintaining patient safety, the supervising resident's decision not to report the heparin infiltration incident was a serious mistake that could have significant consequences for patient care.

From the Research

Background on Heparin

• Heparin is a naturally occurring polysaccharide with versatile biological properties, used as a therapeutic anticoagulant for nearly a century 2.
• It has been found to exhibit anti-inflammatory, antiviral, and anti-tumorigenic activities, in addition to its known anticoagulant properties 2, 3.
• Heparin is mainly composed of repeating trisulfated disaccharide units, made by mast cells enriched in the intestines, lungs, or livers of animals 3.

Clinical Use of Heparin

• Unfractionated heparin (UFH) has been the most widely used agent for quickly suppressing thrombosis, but its use is limited by variable pharmacokinetics and potential side effects such as osteoporosis and heparin-induced thrombocytopenia (HIT) 4.
• Low-molecular-weight heparins and synthetic pentasaccharides like fondaparinux have been developed to provide more predictable dosing and fewer adverse effects 4.
• Heparin is used to prevent deep vein thrombosis and pulmonary embolism, and its clinical usage continues to increase 5.

Potential Reasons for Failure to Report Heparin Infiltration

• There are no direct research papers to assist in answering this question, as the provided studies focus on the history, pharmacokinetics, and clinical use of heparin, rather than the specific incident of a supervising resident failing to report heparin infiltration.
• However, it can be inferred that the complexity of heparin's molecular structure and its variable pharmacokinetics may contribute to difficulties in assessing and reporting adverse effects such as infiltration 6, 4.