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Improving Medication Safety with Anticoagulant Therapy

ISMP can assist individual hospitals, healthcare systems, and group collaboratives to improve patient safety by reducing the incidence of errors associated with antithrombotic therapy.  The Institute has compiled a variety of proactive tools, strategies, and resources to assist healthcare organizations identify and remediate error-prone practices that may exist when antithrombotic agents are prescribed, dispensed, and administered  

ISMP Medication Safety Self Assessment® 
for Antithrombotic Therapy

The ISMP Medication Safety Self Assessment® for Antithrombotic Therapy provides organizations with a comprehensive approach to reviewing medication safety practices around the use of antithrombotic agents, including the newer oral anticoagulants. The self assessment is divided into eight key elements that significantly influence the safe use of antithrombotic agents. Each key element is defined by one or more core characteristics of a safe medication system. Self-assessment items are provided to help facilities evaluate their success with achieving each core characteristic. The tool can help organizations recognize specific areas for improvement by identifying the system weaknesses in their current antithrombotic processes. The assessment can be found at:


Failure Mode and Effects Analysis for Anticoagulants

A sample Failure Mode and Effects Analysis (FMEA) for anticoagulant therapy is available at
Facilities can use this tool to analyze their unique vulnerabilities by scoring the probability of failure as well as the ability to detect an error before it reaches a patient.  To help with this process, ISMP has included the severity score for each failure mode.

Audio Teleconferences CDs Available

ISMP conducts teleconferences on a variety of medication safety topics. CDs of several past programs on anticoagulant and antithrombotic therapy, Reducing the Risk of Patient Harm with Anticoagulant Therapy and Improving Medication Safety with Antithrombotic Agents are available for purchase. Upcoming programs can be found at

Featured Newsletter Articles

ISMP has published several articles and case studies on errors involving anticoagulant and antithrombotic therapy in its ISMP Medication Safety Alert!® newsletters. One feature article can be viewed at Subscription information and CDs of past issues can be found at

Other Services from ISMP

Risk Assessments

Objective onsite medication use evaluations facilitated by an interdisciplinary ISMP team can assist leadership in developing and implementing organizational-specific, high-leverage medication safety improvements. The Institute is also available to perform an in-depth Root Cause Analysis (RCA) arising from an error in the delivery of antithrombotic medications. A full list of services can be obtained at

Group Collaboratives

The ISMP team can facilitate onsite and offsite support services (workshops, educational programs, and self assessment initiatives) for various sized groups wishing to undertake a medication safety initiative.

Educational Programs

ISMP’s unparalleled educational programs provide independent and unbiased information. Programs and sessions cover a wide variety of venues, including freestanding events, teleconferences, and lectures at hospitals or other healthcare settings. Further information can be found at

The Joint Commission National Patient Safety Goal 3E


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