TY  - JOUR
PY  - 2021//
TI  - Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using reason's accident causation theory
JO  - International journal of clinical pharmacy
A1  - Haque, Hazera
A1  - Alrowily, Abdulrhman
A1  - Jalal, Zahraa
A1  - Tailor, Bijal
A1  - Efue, Vicky
A1  - Sarwar, Asif
A1  - Paudyal, Vibhu
SP  - ePub
EP  - ePub
VL  - ePub
IS  - ePub
N2  - Background Direct oral anticoagulants (DOACs) have revolutionised anticoagulant pharmacotherapy. However, DOAC-related medication incidents are known to be common. <br><br>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. <br><br>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. <br><br>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. <br><br>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.<p />  <p>Language: en</p>
LA  - en
SN  - 2210-7703
UR  - http://dx.doi.org/10.1007/s11096-021-01302-6
ID  - ref1
ER  -