Types and causes of anticoagulant‐related medication incidents across hospitals in Western Australia

Abstract

BackgroundAnticoagulant medications are widely prescribed for the treatment and prevention of thromboembolic disorders. They are considered high‐risk medications due to their narrow therapeutic window and potential to cause serious fatal haemorrhagic or thromboembolic complications.AimThis study analysed all reported medication safety incidents related to anticoagulants across Western Australian (WA) public hospitals over a 12‐month period to determine possible causative factors.MethodsA mixed‐methods study of all reported anticoagulant‐related medication incidents between 1 July 2016 and 30 June 2017 across 93 WA public hospitals was conducted. The study identified the confirmed level of harm that occurred to patients, the phase during the medication management cycle when the incident occurred, the incident type and causative factors.ResultsSix per cent (n = 417) of all medication‐related clinical incidents reported during the study period involved anticoagulants, of which 0.2% caused significant harm and 6.7% caused moderate harm. Most incidents occurred during the administration phase (69.1%). The most frequent incident type reported was omission of dose (29.5%) and the most frequent causative factors reported were inadequate checking process (20.7%; n = 746) and inadequate documentation (18.8%).ConclusionMost anticoagulant incidents occurred during the administration phase, with inadequate checking processes and incomplete or illegible documentation being the most frequently reported causative factors. Review of direct oral anticoagulant‐reported incidents identified staff knowledge deficits with regard to indication‐based dosing and dose modification requirements in renal impairment. These findings contributed towards development of targeted strategies and education resources to reduce the incidence of anticoagulant‐related medication incidents.

Opioid related medication incidents in Western Australia public hospitals: types, causes and level of harm

“…12,13,18 This is useful information, as the phase in the medication management cycle in which an incident occurs highlights the types of prevention strategies that could be used to mitigate errors. 11 For example, administration errors could be reduced via improved clinical communication and the provision of staff training, programs and resources (e.g. improved knowledge of pain management policies and guidelines; increased information about common opioid errors; improved awareness of the importance of patient factors such as co-morbidities, age, past opioid use and substance abuse history).…”

“…improving the legibility and completeness of medication orders), providing computerised provider order entry, and by providing prescribers with decision support. 11,13 Compared to hand written opioid prescriptions, eMMS are less likely to contain deviations from best-practice such as missing patient identifiers, errorprone abbreviations, illegible or incomplete text and medication errors (e.g. name, dose, frequency).…”

“…12,22 Two other causative themes that featured prominently in the study were 'inadequate documentation' and 'inadequate clinical handover', both communication factors that are crucial to safe medication practices. 11 Strategies to reduce communication errors could include improved documentation of a patient's current medications and previous opioid use on admission 6,22 as well as an upgrade in the standardisation of important processes such as patient handover. 25 Strengths and limitations of the study…”

“…10 Medications are the most common form of treatment given to patients in a health setting and therefore also have a high rate of clinical incidents and potential to cause harm if not prescribed, dispensed or administered correctly. 11 Medication incidents in hospitals are common and occur at all phases of the medication management cycle. 12 Opioids are among the most frequently used medication in hospitals.…”

“…A clinical incident is an event or circumstance resulting from health care which could have or did lead to unintended and/or unnecessary harm to a patient 10 . Medications are the most common form of treatment given to patients in a health setting and therefore also have a high rate of clinical incidents and potential to cause harm if not prescribed, dispensed or administered correctly 11 . Medication incidents in hospitals are common and occur at all phases of the medication management cycle 12 .…”