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We read with great interest the recent publication by Lui et al in the May 2025 issue, entitled ‘Improving the Safety of Heparin Usage by Standardization Practice’. We applaud their quality improvement initiative, which addresses the challenges of managing heparin—a well-known high-risk medication—and aligns closely with both the Anticoagulation Forum’s concept of anticoagulation stewardship and the Joint Commission’s National Patient Safety Goals.1 The authors highlight the risks and practical challenges associated with heparin, underscoring the importance of their work. Building on their discussion, we wish to expand on the broader limitations of heparin—limitations that clinicians have long accepted due to established practice, experience and cost. We also extend this reflection to other anticoagulants, many of which have not yet delivered the anticipated advantages over heparin.