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Published on: October 12, 2012
Anticoagulant medication errors in hospitals and primary care: a cross-sectional study
Albert R Dreijer1,2, Jeroen Diepstraten2, Vera E Bukkems1
1Department of Hospital Pharmacy, Erasmus University Medical Center, 3015 CN, Rotterdam, The Netherlands.
Objective:
To assess the proportion of all medication error reports in hospitals and primary care that involved an anticoagulant. Secondary objectives were the anticoagulant involved, phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. Additional secondary objectives were the total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month and the proportion of causes of 1000 anticoagulant medication errors (comparing the pre- and post-guideline phase).
Design:
A cross-sectional study.
Setting:
Medication errors reported to the Central Medication incidents Registration reporting system.
Participants:
Between December 2012 and May 2015, 42 962 medication errors were reported to the CMR.
Intervention:
N/A.
Main Outcome Measure:
Proportion of all medication error reports that involved an anticoagulant. Phase of the medication process in which the error occurred, causes and consequences of 1000 anticoagulant medication errors. The total number of anticoagulant medication error reports per month, divided by the total number of medication error reports per month (comparing the pre- and post-guideline phase) and the total number of causes of 1000 anticoagulant medication errors before and after introduction of the LSKA 2.0 guideline.
Results:
Anticoagulants were involved in 8.3% of the medication error reports. A random selection of 1000 anticoagulant medication error reports revealed that low-molecular weight heparins were most often involved in the error reports (56.2%). Most reports concerned the prescribing phase of the medication process (37.1%) and human factors were the leading cause of medication errors mentioned in the reports (53.4%). Publication of the national guideline on integrated antithrombotic care had no effect on the proportion of anticoagulant medication error reports. Human factors were the leading cause of medication errors before and after publication of the guideline.
Conclusions:
Anticoagulant medication errors occurred in 8.3% of all medication errors. Most error reports concerned the prescribing phase of the medication process. Leading cause was human factors. The publication of the guideline had no effect on the proportion of anticoagulant medication errors.
Insights
Anticoagulant medication errors represent 8.3% of all reported errors, frequently involving low-molecular weight heparins during the prescribing phase. Human factors are the primary cause, with a national guideline showing no impact on error rates.
Area of Science:
- Pharmacovigilance
- Patient Safety
- Medication Error Analysis
Background:
- Medication errors pose a significant threat to patient safety.
- Anticoagulants, due to their narrow therapeutic index, are high-risk medications prone to errors.
Purpose of the Study:
- To determine the proportion of medication errors involving anticoagulants.
- To identify the types of anticoagulants involved, error phases, causes, and consequences.
- To assess the impact of a national guideline on anticoagulant medication error rates.
Main Methods:
- A cross-sectional study analyzing medication error reports from the Central Medication incidents Registration (CMR) system.
- Data collected from December 2012 to May 2015, encompassing 42,962 medication errors.
- Analysis focused on the proportion of anticoagulant errors, error phases, causes, and comparison pre- and post-guideline implementation.
Main Results:
- Anticoagulants accounted for 8.3% of all reported medication errors.
- Low-molecular weight heparins were the most frequently implicated anticoagulant (56.2%).
- The prescribing phase was most affected (37.1%), with human factors being the predominant cause (53.4%).
Conclusions:
- Anticoagulant medication errors constitute a notable portion of overall medication errors.
- Prescribing errors and human factors are key issues in anticoagulant safety.
- The implemented national guideline did not significantly alter the incidence or nature of anticoagulant medication errors.
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