Direct oral anticoagulant-related medication incidents and pharmacists’ interventions in hospital in-patients: evaluation using reason’s accident causation theory

Hazera Haque, Abdulrhman Alrowily, Zahraa Jalal, Bijal Tailor, Vicky Efue, Asif Sarwar, Vibhu Paudyal

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Abstract

Background: Direct oral anticoagulants (DOACs) have revolutionised anticoagulant pharmacotherapy. However, DOAC-related medication incidents are known to be common.

Objective: To assess medication incidents associated with DOACs using an error theory and to analyse pharmacists’ contributions in minimising medication incidents in hospital in-patients.

Setting: A large University academic hospital in the West Midlands of England.

Methods: Medication incident data from the incident reporting system (48-months period) and pharmacists’ interventions data from the prescribing system (26-month period) relating to hospital in-patients were extracted. Reason’s Accident Causation Model was used to identify potential causality of the incidents. Pharmacists’ intervention data were thematically analysed.

Main outcome measure: (a) Frequency, type and potential causality of DOAC-related incidents; (b) nature of pharmacists’ interventions.

Results: A total of 812 reports were included in the study (124 medication incidents and 688 intervention reports). Missing drug/omission was the most common incident type (26.6%, n = 33) followed by wrong drug (16.1%, n = 20) and wrong dose/strength (11.3%, n = 14). A high majority (89.5%, n = 111) of medication incidents were caused by active failures. Patient discharge without anticoagulation supply and failure to restart DOACs post procedure/scan were commonly recurring themes. Pharmacists’ interventions most frequently related to changes in pharmacological strategy, including drug or dose changes (38.1%, n = 262). Impaired renal function was the most common reason for dose adjustments.

Conclusion: Prescribers’ active failure rather than system errors (i.e. latent failures) contributed to the majority of DOAC-related incidents. Reinforcement of guideline adherence, prescriber education, harnessing pharmacists’ roles and mandating renal function information in prescriptions are likely to improve patient safety.
Original languageEnglish
Pages (from-to)1693-1704
Journal International Journal of Clinical Pharmacy
Volume43
Issue number6
Early online date2 Jul 2021
DOIs
Publication statusPublished - Jul 2021

Keywords

  • Causes
  • DOAC
  • Medication incident
  • Pharmacist intervention
  • Reason’s accident causation model

ASJC Scopus subject areas

  • Pharmacy
  • Toxicology
  • Pharmacology
  • Pharmaceutical Science
  • Pharmacology (medical)

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