Multicomponent Pharmacist Intervention Did Not Reduce Clinically Important Medication Errors for Ambulatory Patients...

Area of Science:

• Pharmacology
• Clinical Pharmacy
• Patient Safety

Background:

• Direct oral anticoagulants (DOACs) are high-risk medications requiring careful management.
• Clinically important medication errors (CIMEs) are a concern for patients on DOACs.
• A pharmacist-led intervention was hypothesized to reduce these errors.

Purpose of the Study:

• To evaluate the effectiveness of a multicomponent intervention by clinical pharmacists in reducing CIMEs.
• To assess the impact of a DOAC checklist and pharmacist follow-up on patient safety.

Main Methods:

• A randomized controlled trial involving ambulatory patients initiating or resuming DOACs.
• Intervention included pharmacist evaluation, consultations, hotline access, and monitoring using a DOAC checklist.
• Control group received standard care with affordability assistance.

Main Results:

• The intervention did not significantly reduce anticoagulant-related CIMEs (IRR 1.17) or non-anticoagulant-related CIMEs (IRR 1.05).
• Common errors included missed blood tests and concurrent use of DOACs with aspirin or NSAIDs.
• Despite systematic identification, these errors persisted.

Conclusions:

• A multicomponent intervention by clinical pharmacists using an evidence-based DOAC Checklist did not decrease CIMEs.
• Further strategies may be needed to effectively reduce medication errors associated with DOAC therapy.