PSA Advisories

Oral Anticoagulants: A Review of Common Errors and Risk Reduction Strategies

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. (Pa Patient Saf Advis 2015 Jun;12[2]54-61.)

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