Medication errors involving anticoagulants: Data from the Danish patient safety database

Abstract

Reporting of adverse incidents is mandatory in Denmark. All reported adverse incidents are made anonymously, and stored in an encrypted database. It is the purpose of this descriptive study to describe the severity of adverse medication incidents caused by oral anticoagulants in hospitals. All moderate, severe and fatal reports concerning non‐vitamin K antagonist oral anticoagulants were analyzed from date of marketing until July 8 2014. The data collection for warfarin was from January 1 2014 until July 8 2014. Three independent specialists in clinical pharmacology evaluated the severity of incident outcomes. A total of 147 adverse medication incidents were analyzed, and showed that de facto or potentially fatal and serious incidents were most frequently associated with sector change (admission to or discharge from hospital, or undergoing surgery) and resulted from insufficient or excess dosing. Physicians should be aware when prescribing and changing anticoagulant therapy to avoid severe or fatal incidents.

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

“…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]. Among different error subtypes occurring in the prescribing phase, the wrong dosage and drug omission have been repeatedly found as the most common subtype [3,6,7].…”

“…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.…”

“…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.…”

The patient pathway in cardiovascular care: A position paper from the International Pharmacists for Anticoagulation Care Taskforce (iPACT)

“…However, a study conducted in Denmark with the purpose to describe the severity of adverse medication incidents caused by oral anticoagulants in hospitals showed that all fatal and almost all serious adverse medication incidents were associated with the prescribing phase of the medication process. In addition, during admission and surgery, prescribing excess anticoagulant was the most frequent problem and, on the other side, during discharge, prescribing insufficient anticoagulant was the most frequent problem . As more drugs to improve patient outcomes enter the health care system, potential new interactions become apparent.…”

“…In addition, during admission and surgery, prescribing excess anticoagulant was the most frequent problem and, on the other side, during discharge, prescribing insufficient anticoagulant was the most frequent problem. 89 As more drugs to improve patient outcomes enter the health care system, potential new interactions become apparent. These interactions can impact on a drug's absorption, distribution, metabolism, excretion, or actual clinical effect.…”