Direct oral anticoagulant-related medication incidents and pharmacists’ interventions in hospital in-patients: evaluation using reason’s accident causation theory

Abstract

Background Direct oral anticoagulants (DOACs) have revolutionised anticoagulant pharmacotherapy. However, DOAC-related medication incidents are known to be common. Objective To assess medication incidents associated with DOACs using an error theory and to analyse pharmacists’ contributions in minimising medication incidents in hospital in-patients. Setting A large University academic hospital in the West Midlands of England. Methods Medication incident data from the incident reporting system (48-months period) and pharmacists’ interventions data from the prescribing system (26-month period) relating to hospital in-patients were extracted. Reason’s Accident Causation Model was used to identify potential causality of the incidents. Pharmacists’ intervention data were thematically analysed. Main outcome measure (a) Frequency, type and potential causality of DOAC-related incidents; (b) nature of pharmacists’ interventions. Results A total of 812 reports were included in the study (124 medication incidents and 688 intervention reports). Missing drug/omission was the most common incident type (26.6%, n = 33) followed by wrong drug (16.1%, n = 20) and wrong dose/strength (11.3%, n = 14). A high majority (89.5%, n = 111) of medication incidents were caused by active failures. Patient discharge without anticoagulation supply and failure to restart DOACs post procedure/scan were commonly recurring themes. Pharmacists’ interventions most frequently related to changes in pharmacological strategy, including drug or dose changes (38.1%, n = 262). Impaired renal function was the most common reason for dose adjustments. Conclusion Prescribers’ active failure rather than system errors (i.e. latent failures) contributed to the majority of DOAC-related incidents. Reinforcement of guideline adherence, prescriber education, harnessing pharmacists’ roles and mandating renal function information in prescriptions are likely to improve patient safety.

Improving appropriate use of anticoagulants in hospitalised patients: A pharmacist‐led Check of Medication Appropriateness intervention

“…Most of our recommendations pertained to inappropriate NOAC dosing (68.6%). This was also observed in other studies evaluating pharmacist‐led interventions for NOAC treatments 13–16 . The clinical rules on NOAC dosing considered a multitude of decision modifiers, including indication, renal function and age, but also contraindications and clinically relevant drug interactions.…”

“…This was also observed in other studies evaluating pharmacist-led interventions for NOAC treatments. [13][14][15][16] The clinical rules on NOAC dosing considered a multitude of decision modifiers, including indication, renal function and age, but also contraindications and clinically relevant drug interactions. These many factors add to the difficulty of selecting the correct dose.…”

“…12 Also, pharmacistled clinical services including reviewing all orders for NOACs can reduce the number of inappropriate prescriptions of these drugs. [13][14][15][16] Such interventions are, however, time and personnel intensive, limiting their efficacy to change hospital-wide prescribing behaviours.…”

“…The S‐team study recently showed that implementation of hospital‐based anticoagulant stewardship programmes had a significant impact on bleeding and thrombotic events and resulted in lower all‐cause mortality 12 . Also, pharmacist‐led clinical services including reviewing all orders for NOACs can reduce the number of inappropriate prescriptions of these drugs 13–16 . Such interventions are, however, time and personnel intensive, limiting their efficacy to change hospital‐wide prescribing behaviours.…”

Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis

“…In addition, well-known causes of medication errors under-reporting such as perceived fears of blame, punishment, or indemnity either by patients, clinicians or administration, consequences of reporting protocol, heavy workload, and lack of time will impede estimating the true prevalence of actual errors reported in the included studies [ 56 ]. Therefore, studies that rely on incident reporting databases to identify error rates are likely to be provide underestimation of true prevalence [ 57 ].…”