Oral anticoagulants: a review of common errors and risk reduction strategies

Oral anticoagulants: a review of common errors and risk reduction strategies

Collection:
Health Policy and Services Research
Series Title(s):
Pennsylvania patient safety advisory
Author(s):
Andreica, Ivyruth, author
Grissinger, Matthew, author
Contributor(s):
Pennsylvania. Patient Safety Authority, issuing body.
ECRI (Organization), issuing body.
Institute for Safe Medication Practices, issuing body.
Publication:
[Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, June 2015
Language(s):
English
Format:
Text
Subject(s):
Anticoagulants -- adverse effects
Anticoagulants -- therapeutic use
Medication Errors -- prevention & control
Medication Therapy Management
Pennsylvania
United States
Genre(s):
Technical Report
Abstract:
Oral anticoagulants, a class of high-alert medications, are widely used in the United States for varying indications, including treatment after deep-vein thrombosis or pulmonary embolism as well as prevention of stroke in valvular and non-valvular-related atrial fibrillation. Analysts reviewed medication error reports submitted from July 2013 through June 2014 through the Pennsylvania Patient Safety Reporting System (PA-PSRS) involving four oral anticoagulants: warfarin, apixaban, rivaroxaban, and dabigatran. Of the 831 errors related to oral anticoagulants analyzed from PA-PSRS, the most common event types were drug omissions (32.5%, n = 270), other (18.5%, n = 154), and extra doses (11.7%, n = 97). Medication errors categorized as "other" involved problems related to prescribing, wrong dose, wrong patient, and inaccurate medication lists. Risk reduction strategies include establishing functional hard-stop drug alerts during order entry, establishing an anticoagulant management service program, and providing continuous education for staff on anticoagulant use.
Copyright:
Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
Extent:
1 online resource (1 PDF file (pages 54-61))
Illustrations:
Illustrations
NLM Unique ID:
101661140 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/101661140