The Pennsylvania Patient Safety Reporting System (PA-PSRS) received reports of Serious Event between June 2004 and January 2008 associated with the prescribing, dispensing, administering, and/or monitoring of anticoagulation therapy (see Table 1). Patient outcomes included hematologic effects from thrombocytopenia to hemorrhage; many patients required transfusions; some patients died.
Stages in Anticoagulation Therapy* |
Number of Serious Events |
Percentage (%) |
Prescribing | 35 | 6 |
Dispensing | 44 | 7 |
Administering | 94 | 16 |
Monitoring | 202 | 34 |
Other (e.g., bleeding, falls with hematoma, pressure ulcers) | 327* | 55 |
Total Number of Reports | 591† | |
* May not be included in any stage of anticoagulation therapy † Serious events may include multiple overlapping stages throughout anticoagulation therapy | | |
Excerpted from: Anticoagulation management service: safer care, maximizing outcomes. Pa Patient Saf Advis 2008 Sep. http://patientsafety.pa.gov/ADVISORIES/Pages/200809_81.aspx.
In a more recent analysis of 831 medication error reports associated with oral anticoagulants reported through PA-PSRS from July 2013 through June 2014, the greatest number of errors were reported as drug omissions (32.5%, n = 270), “other” (18.5%, n = 154), and extra doses (11.7%, n = 97) (see Table 2).
Event Type | N |
% |
Dose omission | 270 | 32.5 |
Other (specify) | 154 | 18.5 |
Extra dose | 97 | 11.7 |
Wrong dose/overdosage | 50 | 6.0 |
Monitoring error: clinical (lab value, vital sign) | 46 | 5.5 |
Wrong time | 40 | 4.8 |
Unauthorized drug | 34 | 4.1 |
Wrong dose/underdosage | 28 | 3.4 |
Wrong patient | 23 | 2.8 |
Medication list incorrect | 22 | 2.6 |
Prescription/refill delayed | 20 | 2.4 |
Wrong drug | 14 | 1.7 |
Monitoring error: drug-drug interaction | 8 | 1.0 |
Wrong duration | 5 | 0.6 |
Wrong strength/concentration | 5 | 0.6 |
Wrong technique | 5 | 0.6 |
Monitoring error: other (specify) | 5 | 0.6 |
Wrong dosage form | 2 | 0.2 |
Wrong route | 1 | 0.1 |
Monitoring error: drug-disease interaction | 1 | 0.1 |
Monitoring error: deteriorated drug/biologic | 1 | 0.1 |
Excerpted from: Andreica I, Grissinger M. Oral
anticoagulants: a review of common errors and risk reduction strategies. Pa Patient Saf Advis 2015 Jun. http://patientsafety.pa.gov/ADVISORIES/Pages/201506_54.aspx.