Impact of a pharmacist‐to‐dose direct oral anticoagulant protocol on medication errors at an academic medical center

Abstract

Background: Direct oral anticoagulants (DOACs) are considered high-risk medications and pose a serious threat to patients if mismanaged. Furthermore, medication error rates involving DOACs in the acute care setting range from 25% to 40%. To reduce medication error rates at our institution, we implemented a pharmacist-driven DOAC protocol that permitted pharmacists to independently order and monitor DOACs pursuant to a consult order.Objective: To determine the impact of a pharmacist-to-dose DOAC protocol on medication errors at an academic medical center.Methods: This was a retrospective, single-center cohort study using a pre-post design to evaluate the impact of a pharmacist-to-dose DOAC protocol on rates of medication errors. Patient data were evaluated during a 6-month period before and after the implementation of the protocol. Patients were excluded if they were receiving a DOAC for an indication other than venous thromboembolism and/or atrial fibrillation.Results: A total of 502 patients (pre-phase = 256; post-phase = 246) admitted to the hospital and receiving a DOAC were included in the study. A total of 41 patients in the pre-phase received a medication error involving a DOAC compared with 22 patients in the post-phase (16% vs 8.9%; relative risk reduction 44%; P = .017).Rates of near misses were numerically higher in the post-phase group (7.4% vs 11.8%; P = .1), and rates of discharge DOAC errors were numerically lower (8.5% vs 4.9%; P = .1). The most common error was underdosing (N = 31). Conclusion:In this study, the implementation of a pharmacist-to-dose DOAC protocol was associated with a 44% reduction in DOAC-related medication errors. These findings underscore the impact of a protocolized approach to DOAC management, as well as the role of pharmacists in overseeing inpatient DOAC use and reducing medication errors.

Inpatient pharmacy‐driven antithrombosis stewardship efforts on warfarin to direct oral anticoagulant conversions

“…Multiple studies have demonstrated the ability of pharmacist‐run stewardship initiatives in both inpatient and outpatient settings to optimize appropriate prescribing and dosing of DOACs 14,33 . In one study, implementation of a pharmacist‐to‐dose DOAC protocol was associated with a 44% reduction in DOAC‐related medication errors in hospitalized patients 14 .…”

“…Pharmacists are well‐equipped to optimize guideline‐directed anticoagulant therapy by identifying and converting appropriate patients. Several studies have demonstrated a positive effect of pharmacist‐led anticoagulation stewardship in improving appropriate DOAC prescribing 12–14 . A recent article by Kish and colleagues described a warfarin to DOAC conversion initiative during the coronavirus disease 2019 (COVID‐19) pandemic in pharmacist‐led anticoagulation clinics utilizing a “DOAC conversion checklist.” 15 However, data describing the impact of pharmacist‐driven anticoagulation (AC) stewardship in the inpatient setting is currently lacking.…”

Views, experiences and contributory factors related to medication errors associated with direct oral anticoagulants: a qualitative study with physicians and nurses

“…Our results showed that participants' confidence in prescribing DOACs to patients were boosted if they collaoborated with clinical pharmacists. Studies have shown that involvement of pharmacists in the appropriate selection of DOACs doses decreased errors [21,22]. Additionaly, pharmacists were able to reduce DOACs errors through medications reviews conducted during the hospital stay, at the clinics and through medication reconciliation [21,22].…”

A call to action for anticoagulation stewardship

“…Unlike conventional anticoagulation management, which is often siloed and focused solely on drug management, anticoagulation stewardship provides a holistic approach that spans the continuum of care, is focused on continuous quality improvement, and addresses patient‐level, clinician level, and system‐level barriers and opportunities to improve patient care. To address the ongoing pervasiveness of inappropriate anticoagulant prescribing and management, a growing number of health care institutions across the United States and globally have successfully implemented anticoagulation stewardship initiatives and assessed their impact in both inpatient and outpatient clinical settings 19–21 …”

“…To address the ongoing pervasiveness of inappropriate anticoagulant prescribing and management, a growing number of health care institutions across the United States and globally have successfully implemented anticoagulation stewardship initiatives and assessed their impact in both inpatient and outpatient clinical settings. [19][20][21] Koolian et al 16…”