Anticoagulant medication errors in hospitals and primary care: a cross-sectional study

Dreijer, Albert R; Diepstraten, Jeroen; Bukkems, Vera E.; Mol, Peter G. M.; Leebeek, Frank W.G.; Kruip, Marieke J.H.A.; Bemt, Patricia M. L. A. van den

doi:10.1093/intqhc/mzy177

Cited by 22 publications

(27 citation statements)

References 24 publications

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“…anticoagulant-related medication errors occurred mainly in the prescribing phase and in about 56% of errors lowmolecular-weight heparins (LMWH) were involved [2,4]. Consistently, a similar descriptive study on the Danish patient safety database reported that the adverse medication incidents occurred mainly in the prescribing phase, and in about 80% of incidents the errors occurred at the time of sector changes (at the admission, at the discharge or ward changes) [5].…”

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confidence: 68%

“…Despite similarities of different reports in showing the high frequency of AC-associated medication errors, there are discrepancies regarding involved AKs, the proportion of error types, and the time of medication process in which errors occur. It seems that the following parameters play a role in the above-mentioned discrepancies: time of study according to the first appearance of the newer AK agents, pharmaceutical market varieties among countries in which the studies have been done, and the difference in study population [2,24].…”

Section: Discussionmentioning

confidence: 99%

“…From this population, all patients admitted to our in-patient wards, from 21.08.2017-20.08.2018, who concomitantly received at least two ACs were included in the study. Subsequently, the following patients have been excluded: [1] patients who received the anticoagulants separately, no overlapping prescription [2] patients treated with the combination of heparin/ heparin analogs and vitamin-K antagonists (VKA) [3] patients receiving heparin/ heparin analogs based on a weekly schedule such as patients with hemodialysis [4] patients receiving low-dose alteplase (= < 4 mg) as a catheter locking solution [5] patients treated with the combination of VKA and direct oral anticoagulants (DOACs) during bridging from DOACs to VKA [6] patients who explicitly refused participation in research.…”

Section: Patient Populationmentioning

confidence: 99%

“…Accordingly, the AC-related errors occur in about 78% of cases in adults older than 60 and in about one third in patients older than 80 years old [9]. The studies reporting the frequency and complications of AK-related medication errors have been mostly done based on data reported to in-house or nation-wide drug safety systems [2,3,[5][6][7][8][9][10]. As many of these errors could not be detected or have not been reported by medical staff, the studies based on them could not reliably show the incidence of errors, the affected population and the rate of consequences.…”

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confidence: 99%

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Therapeutic duplication of anticoagulants: a retrospective study of frequency and consequences in a tertiary referral hospital

et al. 2020

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Background: Anticoagulants are commonly prescribed in medical practices and could be of significant harm in the case of medication errors. We conducted a retrospective observational study to determine the frequency and consequences of the therapeutic duplication of anticoagulants (TDA). As a secondary objective, we aimed to determine the characteristics of the population in which TDA occurs. Methods: We conducted a retrospective observational study among admitted patients who concomitantly received at least two anticoagulants from August 2017 to August 2018. Results: A total of 107 patients with TDA are included in the research. The patients with TDA have a mean age of 73. The TDA population has a high rate of associated comorbidities with 69% of patients having arterial hypertonia, 40% with chronic kidney disease, 26% with a history of malignancy, and 20.5% with a history of stroke. More than 65% of patients were under anticoagulation before admission, mostly due to atrial fibrillation. The TDA occurred in more than 95% of cases in the first week or the last week of hospitalization. Patients had a high risk of bleeding prior to the TDA-event with about 62.5% of TDA patients having a HAS-BLED score at least 3. A total of 8 patients showed a significant Hemoglobin (Hb)-drop of at least 10 g/L within 24 h after TDA-event. Two patients had a new or worsened hematuria following TDA-event. Conclusion: TDA occurred in 0.8% of patients who were under anticoagulation and in 6.7% of patients who received direct oral anticoagulants (DOACs). TDA led in about 7.4% of cases to hemoglobin-relevant bleeding. The old patients with significant comorbidities and a high HAS-BLED score were mainly affected. The female gender and presence of anemia independently predicted the occurrence of bleeding following TDA.

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confidence: 68%

Section: Discussionmentioning

confidence: 99%

Section: Patient Populationmentioning

confidence: 99%

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confidence: 99%

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Therapeutic duplication of anticoagulants: a retrospective study of frequency and consequences in a tertiary referral hospital

et al. 2020

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“…The PPS has proven to be useful to evaluate MRPs as e.g. medication errors relating to anticoagulants, problems related to IT‐matters, or problems related to automatic dose dispensing 22–24 . A systematic evaluation of any MRP relevant to older people and (potentially) connected with the drug product design has not yet been conducted.…”

Section: Introductionmentioning

confidence: 99%

Opportunities for changes in the drug product design to enhance medication safety in older people: Evaluation of a national public portal for medication incidents

Karapinar-Çarkıt

Bemt

Sadik

et al. 2020

Brit J Clinical Pharma

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Aims Medication safety requires urgent attention in hospital pharmacy. This study evaluated the medication‐related problems/errors as reported to the Dutch medication incident registry and disseminated for information to pharmacists. Through analysis by an expert panel we aimed to better understand which problems could have been mitigated by the drug product design. Additionally, the (wider) implications of the problems for current hospital/clinical practice were discussed. Methods Items were extracted from the public Portal for Patient Safety. Items were included if relevant for older people and connected with the drug product design and excluded if they should reasonably have been intercepted by compliance to routine controls or well‐known professional standards in pharmaceutical care. To explore any underreporting of well‐known incidents, it was investigated if different medication‐related problems could be observed in a regional hospital practise over a 1‐month period. For 6 included items (cases), the implications for hospital/clinical practise were discussed in an expert panel. Results In total, 307 items were identified in the Portal for Patient Safety; all but 14 were excluded. Six cases were added from daily hospital practice. These 20 cases commonly related to confusing product characteristics, packaging issues such as the lack of a single unit package for an oncolytic product, or incorrect or incomplete user instructions. Conclusion Medication registries provide important opportunities to evaluate real‐world medication‐related problems. However, underreporting of well‐known problems should be considered. The product design can be used as an (additional) risk mitigation measure to support medication safety in hospital practice.

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Approaches to Precision‐based Anticoagulation management in the critically Ill

Dager,

Trujillo,

Gilbert

2023

Pharmacotherapy

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Anticoagulant therapy is commonly associated with a high incidence of avoidable adverse events, especially in the acute care setting. This has led to several initiatives by key national health care stakeholders, including specific attention to The Joint Commission's National Patient Safety Goals, to improve anticoagulation management. The subject of special populations has long been identified as challenging by clinicians with the use of anticoagulants. This is driven in part by numerous variables that can contribute to hard outcomes such as bleeding, thrombosis, length of stay, hospital re‐admission, morbidity, and mortality. Despite the notable effort to improve the use of anticoagulants with numerous clinical trials, guidelines, guidance statements, and other sources of published evidence, notable difficulties continue to challenge practitioners in managing this class of medications. This is especially the case with very diverse critically ill populations where countless variables exist, many of which were never explored in trials or have historically been frequently excluded. Trials evaluating anticoagulation therapy often can only account for small portions of variables that may affect thrombosis and hemostasis, and study methods often do not reflect the constantly changing dynamic conditions seen in unique critically ill patients. Clinicians providing care to the numerous critically ill populations are faced with conditions that lead to relatively small therapeutic windows, which makes designing safe optimal anticoagulation management plans difficult when dealing with complex patients and mechanical support devices. The approach to crafting a successful management plan for anticoagulant therapy must incorporate the numerous variables that are continuously assessed and revised during the patient's time in the intensive care unit. We explore considerations and approaches when developing, assessing, and implementing an individualized or precision‐based management plan that involves the use of anticoagulants in the critically ill. The skills and thought process provided will assist clinicians in managing this unique, variable, and challenging population.

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Anticoagulant medication errors in hospitals and primary care: a cross-sectional study

Abstract: Anticoagulant medication errors occurred in 8.3% of all medication errors. Most error reports concerned the prescribing phase of the medication process. Leading cause was human factors. The publication of the guideline had no effect on the proportion of anticoagulant medication errors.

Cited by 22 publications

References 24 publications

Therapeutic duplication of anticoagulants: a retrospective study of frequency and consequences in a tertiary referral hospital

Therapeutic duplication of anticoagulants: a retrospective study of frequency and consequences in a tertiary referral hospital

Opportunities for changes in the drug product design to enhance medication safety in older people: Evaluation of a national public portal for medication incidents

Approaches to Precision‐based Anticoagulation management in the critically Ill

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