Patient Safety Topics
:
Anticoagulation Management
Overview

The complexity of anticoagulants has resulted in patient safety compromise. Healthcare organizations have increasingly recognized the benefits of anticoagulation management services (AMS) in the inpatient and outpatient settings. This collection of resources about AMS may help facilities outline the positive impact that an AMS program will have to provide safer care and maximize patient outcomes.

Key Data and Statistics

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.

Table 1. Serious Events Reported through PA-PSRS related to Anticoagulation Therapy Since 2004

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).  

Table 2. Number of Oral-Anticoagulant-Related Medication Errors, by Event Type, Reported to the Pennsylvania Patient Safety Authority, July 2013 through June 2014 (N = 831) ​ ​
Event TypeN %

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.
Educational Tools

​Organization Assessment of Safe Anticoagulant Practices
This sample tool can help facilities assess the safety of anticoagulant practices and identify opportunities for improvement.

Anticoagulation Management Service: Providing Safer Care Along the Continuum
This research poster illustrates key components to consider when developing an anticoagulation management service. The poster is sized for large-format printing resolution (40 x 40 inch).

Multimedia

​Visit this section in the future for any multimedia associated with this patient safety topic.

Safety Tips for Patients