Background

• FMC’s Quality Department noticed a spike in medication event reports that were associated with the usage of heparin infusion titrations throughout 2021 – 2022
• Most event reports were classified as “near miss”
• FMS’s Executive Leadership tasked the hospital quality, nursing, and pharmacy leaders to identify the issue and make corrections to the existing heparin titration protocol

Objectives

Assumption: There is an excessive diversion of responsibility throughout the tasks surrounding the heparin infusion titration protocol

Action: Design a new heparin titration protocol that focuses responsibility on nursing staff to accurately follow

Hypothesis: The revised heparin infusion protocol will lead to improved patient care outcomes and increased staffing adherence metrics when compared to the previous protocol

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