Abstract
Heparin, a blood thinner used to treat several conditions, must be titrated carefully to avoid adverse effects. An 18-hospital healthcare system tasked a Human Factors Engineering (HFE) team with identifying factors that contribute to the six most common kinds of heparin administration errors across its enterprise. The HFEs conducted an ethnographic study that included interviewing and/or observing three nurses from each of the eight units. Data produced from those activities were analyzed using a SEIPS (Systems Engineering Initiative for Patient Safety) approach, creating two SEIPS 101 tools: a PETT (People, Environment, Tools, Tasks) scan and tools and tasks matrices, to help understand how interactions between nurses and the tools they use when completing heparin management tasks may contribute to errors. The HFE team then developed a set of recommendations to mitigate these errors. These recommendations were grouped into four categories—technology, nurse-driven heparin protocol, reminders, and training.