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Mind on Autopilot: Heparin vs. Insulin

How is it possible that when you’re driving home from work, you have no awareness of the trip?

The American Psychological Association (APA) has published a study on a phenomenon called inattentional blindness. Cognitive scientists once assumed that visual perception is like a videotape–which the mind records what the eyes take in. But increasingly, studies of visual perception have demonstrated how startlingly little people see when we’re not paying attention, a phenomenon known as “inattentional blindness.” Take into account when you are giving heparin to your patients. You have given the same medication a thousand times and your body just goes with that autopilot mindset and muscle memory. Then you were assigned to one diabetic patient during your shift who is receiving regular insulin on a sliding scale. Your mind would say pull up 100 units of insulin via a syringe but you actually pulled up 1 ml of insulin using tuberculin syringe.

The Institute for Safe Medication Practices (ISMP) recommends the following additional strategies to prevent confusion between heparin and insulin vials during drug preparation:

  • Do not keep insulin and heparin vials alongside one another on top of counters or drug carts, or under the laminar flow IV admixture hood in the pharmacy, or near the location where TPN is prepared
  • Consider providing insulin to patient care units in pen devices rather than vials
  • When insulin is needed for an IV, it should be retrieved and added separately from other ingredients and returned to the appropriate storage area immediately after use
  • Adding insulin to any IV solution should occur in the pharmacy.
  • Require an independent double-check of IV insulin, IV heparin doses/infusions, TPN solutions
  • Use bar-code scanning for drug selection



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Action needed to prevent dangerous heparin-insulin confusion. (n.d.). Retrieved February 08, 2017, from

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