Jessica weighs 20 kg. The following infusion order is written by the prescribing physician: “Heparin 400U/hour (20U/kilogram/hour) continuous intravenous infusion.” Jessica is started on the heparin infusion via intravenous route. Four hours later, the nurse notes that Jessica is somnolent. The physician assesses the patient and notes that the infusion rate on the pump administering the heparin is 4000 U/hr. A STAT brain computed tomographic (CT) scan reveals acute intracerebral hemorrhage.
Which of the following is the most likely cause of the adverse drug event (ADE) in this patient? (select only one)
Misinterpretation of infusion dose due to use of abbreviations
Misinterpretation of infusion rate due to inclusion of both patient-specific and weight-based dose
Use of a continuous intravenous infusion instead of subcutaneous administration
Lack of laboratory monitoring
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