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

Area of Science:

• Pharmacology
• Patient Safety
• Drug Surveillance

Background:

• Mandatory adverse incident reporting in Denmark ensures data collection.
• Anonymized and encrypted data storage enhances data security.
• Oral anticoagulants are critical for preventing thrombosis but carry bleeding risks.

Purpose of the Study:

• To describe the severity of adverse medication incidents associated with oral anticoagulants in hospitals.
• To analyze incidents involving non-vitamin K antagonist oral anticoagulants and warfarin.
• To identify factors contributing to severe or fatal anticoagulant-related events.

Main Methods:

• Descriptive study analyzing anonymized adverse incident reports.
• Inclusion of moderate, severe, and fatal incidents for non-vitamin K antagonists (from market launch to July 2014) and warfarin (Jan-July 2014).
• Independent evaluation of incident severity by three clinical pharmacology specialists.

Main Results:

• Analysis of 147 adverse medication incidents.
• Most severe and potentially fatal incidents occurred during sector changes (hospital admission/discharge, surgery).
• Insufficient or excess dosing was a primary cause of severe events.

Conclusions:

• Physicians must exercise caution when prescribing and adjusting anticoagulant therapy.
• Awareness of risks during transitions of care is essential to prevent severe or fatal outcomes.
• Improved medication management strategies are needed for oral anticoagulants.