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Medication errors associated with anticoagulant therapy in the hospital
John Fanikos1, Carl Stapinski, Sophia Koo
1Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02215, USA.
The American Journal of Cardiology
|August 25, 2004
Summary
Hospitalized patients frequently experience medication errors during anticoagulation therapy. A review found 1.67 errors per 1,000 patients, primarily with unfractionated heparin, leading to interventions for some.
Area of Science:
- Pharmacology
- Patient Safety
- Internal Medicine
Background:
- Anticoagulant medications are critical for preventing thrombotic events in hospitalized patients.
- Medication errors associated with anticoagulation pose a significant risk to patient safety.
Purpose of the Study:
- To quantify the incidence and severity of medication errors in hospitalized patients receiving anticoagulation.
- To identify the specific anticoagulant agents most frequently involved in medication errors.
Main Methods:
- A retrospective review of consecutively reported, anticoagulation-related medication errors over a 3-year period.
- Analysis of error frequency, associated drug, and patient outcomes including medical intervention and hospitalization duration.
Main Results:
- A total of 130 medication errors were identified, with an incidence of 1.67 errors per 1,000 anticoagulant patient-days.
- Unfractionated heparin was the most common agent involved (66.2%), followed by warfarin (21.5%).
- While no deaths occurred, 6.2% of affected patients required medical intervention and 1.5% experienced prolonged hospitalization.
Conclusions:
- Medication errors are a common occurrence in hospitalized patients undergoing anticoagulation therapy.
- The findings highlight the need for improved safety protocols and monitoring for anticoagulation, particularly with unfractionated heparin.