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.
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 language | English |
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Pages (from-to) | 1693-1704 |
Journal | International Journal of Clinical Pharmacy |
Volume | 43 |
Issue number | 6 |
Early online date | 2 Jul 2021 |
DOIs | |
Publication status | Published - 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)