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The Most Common Med Errors With Anticoagulants

August 16, 2016

Matthew Grissinger, RPh, FISMP, FASCP, the director of Error Reporting Programs at the Institute for Safe Medication Practices (ISMP), has sifted through more than 540,000 medication error reports submitted by 235 hospitals over the past 12 years. So yeah, he knows a thing or two about drilling down to find out why drug delivery mistakes occur and what can be done to prevent them.

ISMP considers oral anticoagulants high-alert medications, because dose omissions or inappropriate administration can lead to significant patient harm, including potentially fatal thrombosis and bleeding events. Mr. Grissinger recently reviewed 831 error reports related to oral anticoagulant use submitted by Pennsylvania hospitals between July 2013 and June 2014. He noticed some worrisome trends that have him concerned, especially considering the high stakes of ensuring anticoagulants are managed properly from prescribing through to administration.

PLN: What did the report reveal about the real-world management of anticoagulants?

Mr. Grissinger: Anticoagulant omissions, a majority of which involved warfarin, were the most commonly reported event. Unlike other medication therapies that are ordered once for an entire hospital stay, warfarin orders are written every single day based on patients’ most recent INR levels. The communication channels along the pathways of care can get confusing. Are the lab results back to determine if INR levels are within therapeutic range? Is another dose needed? Who’s in charge of calling the prescribing physician to find out? There are a lot of moving parts, and the details of care can slip through the cracks.

PLN: That’s troublesome. What can be done?

Mr. Grissinger: Hospitals should have standard processes in place that detail how to handle oral anticoagulants — this is our anticoagulant of choice, this is when we give it, this is when we hold it, here’s how we monitor the patient, and here’s how we reverse the effects of the drug. Standard order sets can be built to address those variables, so everyone knows anticoagulants are always managed a certain way. Facility-wide education about the proper use of anticoagulants can also be based on standardized protocols, because everyone will be working off the same care plan.

PLN: Is there still a lack of understanding about the proper use of anticoagulants?

Mr. Grissinger: It appears so. We’ve received errors reports that contained troublesome occurrences that weren’t the primary reasons the reports were submitted. For example, one report noted that a physician prescribed 2 new oral anticoagulants at the same time, although the people submitting the report didn’t identify that as their concern. Another report noted that patients with adverse bleeding reactions to new oral anticoagulants were given vitamin K, even though vitamin K doesn’t reverse those agents. I’m convinced prescribing physicians and pharmacists aren’t fully aware of how anticoagulants are dosed, how they work, and, more importantly, how their effects are reversed if something goes wrong.

PLN: What else can be done to improve the safety of anticoagulant therapy?

Mr. Grissinger: Pharmacists should incorporate hard stops into electric drug ordering processes to prevent prescribers from ordering inappropriate doses. Maybe there’s a specific dose threshold of dabigatran that a patient shouldn’t exceed in a single day or, more importantly, maybe the drug’s dose needs to be lowered for an older patient with poor renal function. A hard stop incorporated in the ordering process could alert prescribers that high doses for patients with poor kidney function need to be reduced. Warfarin dosing is very variable — it’s not like every patient receives 2 mg — but you could program in a hard stop for a 20 mg dose, which is extremely high. Some patients might require that dose, but the hard stop would at least make caregivers verify the order and perhaps require them to input a reason as to why they’re overriding it.

PLN: Do pharmacists need to take ownership of anticoagulant programs?

Mr. Grissinger: Absolutely. The error reports we received show the need for improved management of anticoagulants, and I’d love to see more pharmacists run anticoagulation clinics in the outpatient setting and take over anticoagulant dosing on the inpatient side. That’s not always realistic, however, because some smaller hospitals don’t have pharmacists working 24 hours a day, 7 days a week. At the very least, hospitals have to look at the pathway of communication between prescription and administration. That process needs to be consistent, because getting needed medications to patients is a complicated fulfillment process. The more the process is standardized, the safer it will be.


—Dan Cook



Topics like this will be addressed during the "Preventing Errors: Look- and Sound-alike Medications" session at the regional Pharmacy Learning Network meetings. PLN meetings offers health-system pharmacists a full day (6.5 contact hours) of critical education presented by today’s leading experts in the field. Join us in Aurora, Colorado, on September 23. Point of Care Training is also available the following day, September 24.


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