Sources of error in heparin therapy of thromboembolic disease

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Abstract
A series of patients with thromboembolic disease treated i.v. with heparin sodium and monitored by the activated coagulation time (ACT) of whole blood was studied. When patients responded slowly, had dangerous hemorrhage, or had ACT well outside our target range, infusion records were analyzed to determine actual infusion rates. Lack of pump precision, interruption of infusion, errors in making up solutions and failure of infusion or charting techniques were common errors.

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