Harmful Medication Errors Involving Unfractionated and Low-Molecular-Weight Heparin in Three Patient Safety Reporting Programs

Grissinger, Matthew; Hicks, Rodney W.; Keroack, Mark A.; Marella, William; Vaida, Allen J.

doi:10.1016/s1553-7250(10)36032-6

Cited by 24 publications

(29 citation statements)

References 12 publications

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“…With the average patient taking nearly 36 hours to reach a therapeutic level, the data suggest that at least five dosing adjustments are made, introducing multiple opportunities for error, including in assay measurement, results reporting, and medication administration and titration. Because of the need for frequent laboratory testing and dose adjustments, heparin has been labeled as a “high‐risk” drug, having been cited in numerous patient safety incidents …”

Section: Discussionmentioning

confidence: 99%

Analysis of Partial Thromboplastin Times in Patients With Pulmonary Embolism During the First 48 Hours of Anticoagulation With Unfractionated Heparin

Prucnal

Jansson

Deadmon

et al. 2019

Academic Emergency Medicine

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Objective The objective was to determine the proportion of patients with pulmonary embolism (PE) treated with unfractionated heparin (UFH) who achieved therapeutic activated partial thromboplastin time (aPTT) values within 48 hours of treatment. Methods Retrospective analysis of a PE response team (PERT) database was performed at a large, urban, academic teaching hospital. Inclusion criteria were adult patients with acute PE for whom the PERT was consulted and who received anticoagulation (AC) with UFH according to guideline standard dosing. aPTT values during 6‐hour time periods during the first 48 hours of AC were collected and analyzed. Results A total of 505 patients met inclusion criteria. For patients receiving a bolus and infusion of UFH, the proportions (95% confidence interval [CI]) of patients in the therapeutic range were 19.0% (14.2% to 25.0%) at 12 hours, 26.3% (26.3% to 33.1%) at 24 hours, 28.3% (22.0% to 35.4%) at 36 hours, and 28.4% (20.8% to 37.5%) at 48 hours. For titrated infusion only, the proportions (95% CIs) of patients were 23.3% (16.2% to 32.3%) at 12 hours, 41.4% (31.6% to 51.9%) at 24 hours, 37.0% (26.8% to 48.5%) at 36 hours, and 42.1% (30.2% to 55.0%) at 48 hours. No patient had all therapeutic aPTT values. Conclusions The majority of patients with acute PE spend most of their first 48 hours outside of the therapeutic range of AC when treated with guideline standard dosing of UFH. Over half of the patients fail to achieve any therapeutic PTT level within 24 hours of UFH initiation, and no patient had all therapeutic aPTTs. Future research should focus on identifying factors associated with achieving therapeutic AC with UFH.

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Section: Discussionmentioning

confidence: 99%

Analysis of Partial Thromboplastin Times in Patients With Pulmonary Embolism During the First 48 Hours of Anticoagulation With Unfractionated Heparin

Prucnal

Jansson

Deadmon

et al. 2019

Academic Emergency Medicine

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“…Our data corroborate previous reports demonstrating that a substantial proportion of ADEs are due to medication errors and therefore potentially preventable. 4, 5 Computerized provider order entry, 5 improved infusion pump technology, 11 and implementing bar code technology 8, 9 reduce medication errors. However, our root cause analysis suggests that further improvements can be made to reduce anticoagulant-associated medication errors, particularly those due to transcription errors.…”

Section: Discussionmentioning

confidence: 99%

“…1, 4, 6, 11, 14 Despite implementation of computerized provider order entry, electronic medication administration records, and improved infusion pump technology (“smart pumps”), medication errors involving anticoagulant medications remain common. 11, 12 Elderly 15, 16 and cardiac patients 14 represent populations at particularly high risk for suffering anticoagulant-associated ADRs.…”

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confidence: 99%

Anticoagulation-associated Adverse Drug Events

Piazza

Nguyen

Cios

et al. 2011

The American Journal of Medicine

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Purpose Anticoagulant drugs are among the most common medications that cause adverse drug events (ADEs) in hospitalized patients. We performed a five-year retrospective study at Brigham and Women’s Hospital to determine clinical characteristics, types, root causes, and outcomes of anticoagulant-associated adverse drug events (ADEs). Methods We reviewed all inpatient anticoagulant-associated ADEs, including adverse drug reactions (ADRs) and medication errors, reported at Brigham and Women’s Hospital through the Safety Reporting System from May 2004 to May 2009. We also collected data regarding the cost associated with hospitalizations in which ADRs occurred. Results Of 463 anticoagulant-associated ADEs, 226 were MEs (48.8%), 141 were ADRs (30.5%), and 96 (20.7%) involved both a medication error and ADR. Seventy percent of anticoagulant-associated ADEs were potentially preventable. Transcription errors (48%) were the most frequent root cause of anticoagulant-associated medication errors, while medication errors (40%) were a common root cause of anticoagulant-associated ADRs. Death within 30 days of anticoagulant-associated ADEs occurred in 11% of patients. After an anticoagulant-associated ADR, most hospitalization expenditures were attributable to nursing costs (mean $33,189 per ADR) followed by pharmacy costs (mean $7,451 per ADR). Conclusion Most anticoagulant-associated ADEs among inpatients result from medication errors and are therefore potentially preventable. We observed an elevated 30-day mortality rate among patients who suffered an anticoagulant-associated ADE and high hospitalization costs following ADRs. Further Quality Improvement efforts to reduce anticoagulant-associated medication errors are warranted to improve patient safety and decrease health care expenditures.

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“…Various studies document substantial underreporting of incidents among clinicians (108) and explore reasons for failing to report (61). Research comparing information obtained through different reporting systems (80) has found that the information obtained may be redundant (52). In the majority of instances, however, different perspectives provide complementary insights about organizational safety, thus warranting a portfolio of reporting systems.…”

Section: Reporting and Voicing Concernsmentioning

confidence: 99%

Reducing Hospital Errors: Interventions that Build Safety Culture

Singer¹,

Vogus

2013

Annu. Rev. Public Health

153

145

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Hospital errors are a seemingly intractable problem and continuing threat to public health. Errors resist intervention because too often the interventions deployed fail to address the fundamental source of errors: weak organizational safety culture. This review applies and extends a theoretical model of safety culture that suggests it is a function of interrelated processes of enabling, enacting, and elaborating that can reduce hospital errors over time. In this model, enabling activities help shape perceptions of safety climate, which promotes enactment of safety culture. We then classify a broad array of interventions as enabling, enacting, or elaborating a culture of safety. Our analysis, which is intended to guide future attempts to both study and more effectively create and sustain a safety culture, emphasizes that isolated interventions are unlikely to reduce the underlying causes of hospital errors. Instead, reducing errors requires systemic interventions that address the interrelated processes of safety culture in a balanced manner.

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Harmful Medication Errors Involving Unfractionated and Low-Molecular-Weight Heparin in Three Patient Safety Reporting Programs

Cited by 24 publications

References 12 publications

Analysis of Partial Thromboplastin Times in Patients With Pulmonary Embolism During the First 48 Hours of Anticoagulation With Unfractionated Heparin

Analysis of Partial Thromboplastin Times in Patients With Pulmonary Embolism During the First 48 Hours of Anticoagulation With Unfractionated Heparin

Anticoagulation-associated Adverse Drug Events

Reducing Hospital Errors: Interventions that Build Safety Culture

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