Abstract
A case-report is presented of a toddler who received an overdose of argatroban in the cardiac catheterization lab setting due to suspected heparin induced thrombocytopenia. This is the highest known overdose of argatroban in terms of dose-to-weight ratio. The overdose was treated and the patient was recovered in the intensive care unit. Two other adult case reports are discussed and key lessons and suggestions to improve safety for argatroban and for heparin induced thrombocytopenia patients in the hospital setting are also presented.