BackgroundAnticoagulant medications are widely prescribed for the treatment and prevention of thromboembolic disorders. They are considered high‐risk medications due to their narrow therapeutic window and potential to cause serious fatal haemorrhagic or thromboembolic complications.AimThis study analysed all reported medication safety incidents related to anticoagulants across Western Australian (WA) public hospitals over a 12‐month period to determine possible causative factors.MethodsA mixed‐methods study of all reported anticoagulant‐related medication incidents between 1 July 2016 and 30 June 2017 across 93 WA public hospitals was conducted. The study identified the confirmed level of harm that occurred to patients, the phase during the medication management cycle when the incident occurred, the incident type and causative factors.ResultsSix per cent (n = 417) of all medication‐related clinical incidents reported during the study period involved anticoagulants, of which 0.2% caused significant harm and 6.7% caused moderate harm. Most incidents occurred during the administration phase (69.1%). The most frequent incident type reported was omission of dose (29.5%) and the most frequent causative factors reported were inadequate checking process (20.7%; n = 746) and inadequate documentation (18.8%).ConclusionMost anticoagulant incidents occurred during the administration phase, with inadequate checking processes and incomplete or illegible documentation being the most frequently reported causative factors. Review of direct oral anticoagulant‐reported incidents identified staff knowledge deficits with regard to indication‐based dosing and dose modification requirements in renal impairment. These findings contributed towards development of targeted strategies and education resources to reduce the incidence of anticoagulant‐related medication incidents.

Background: Medication incidents in hospitals are common and occur at all phases of the medication management cycle. Clinical incidents for high-risk medications such as opioids have the potential to cause significant harm, yet opioid incidents are an under researched area of health service safety and quality. Aim: The aim of this study was to identify opioid medication safety incident types, occurrence in the medication management cycle, causative factors and level of patient harm to inform clinical care. Method: A multi-methods analysis of all reported opioid-related medication incidents, in all 93 Western Australian (WA) public hospitals, between 1 July 2017 and 30 June 2018 was conducted. Results: Opioid medications as a class were implicated in 11.0% (857) of all medication-related clinical incidents reported in 2017-18, with tapentadol, a relatively new opioid, the most reported (131; 15.3%). No reported incidents resulted in death, however, 0.5% (4) caused severe harm and 3.5% (30) caused moderate harm. The majority of incidents occurred during the administration phase of the medication management cycle (630; 73.5%). 'Incorrect dose' (146; 17%) followed by 'omission of dose' (116; 13.5%) were the most frequent incident types reported. 'Not checking properly' (554; 64.6%) followed by 'not following procedures' (167; 19.5%) were the most frequent causative factors. Conclusion: Vigilance in identifying, reporting and reviewing opioid medication safety incidents and causative factors are imperative to mitigating errors and preventing patient harm. Study findings should be used to develop targeted strategies to reduce opioid incidents in public hospitals.