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 Administration, Oral Anticoagulants -- administration & dosage Drug Monitoring Drug Prescriptions -- standards Inservice Training International Normalized Ratio Risk Management Humans 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