Anticoagulation Management | Patient Safety Topic

Patient Safety Topics

Anticoagulation Management

Overview Key Data & Statistics Educational Tools Multimedia Related Links

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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 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.

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.