PSA Advisories

Oral Anticoagulants: A Review of Common Errors and Risk Reduction Strategies

Oral anticoagulants, a class of high-alert medications, are widely used in the United States for varying indications, including treatment after deep-vein thrombosis or pulmonary embolism as well as prevention of stroke in valvular and non-valvular-related atrial fibrillation. Analysts reviewed medication error reports submitted from July 2013 through June 2014 through the Pennsylvania Patient Safety Reporting System (PA-PSRS) involving four oral anticoagulants: warfarin, apixaban, rivaroxaban, and dabigatran. Of the 831 errors related to oral anticoagulants analyzed from PA-PSRS, the most common event types were drug omissions (32.5%, n = 270), other (18.5%, n = 154), and extra doses (11.7%, n = 97). Medication errors categorized as “other” involved problems related to prescribing, wrong dose, wrong patient, and inaccurate medication lists. Risk reduction strategies include establishing functional hard-stop drug alerts during order entry, establishing an anticoagulant management service program, and providing continuous education for staff on anticoagulant use. (Pa Patient Saf Advis 2015 Jun;12[2]54-61.)

Please click here for the complete article on the Pennsylvania Patient Safety Authority’s website.

More Alerts

Since the 2021-22 influenza (flu) vaccine became available last month, the Institute for Safe Medication Practices (ISMP) has received 16 cases of accidental influenza and coronavirus disease 2019 (COVID-19) vaccine mix-ups. All reports were sent by consumers or healthcare practitioners via one of
ISMP has received reports from two different hospitals about McKesson packaged levetiracetam 250 unit dose blister packages that have a barcode that scans as naproxen 500 mg. Apparently one side of the unit dose blister of 10 levetiracetam tablets scans properly, but the barcode on other side
URGENT – HAZARDOUS SITUATION – PLEASE REACT IMMEDIATELY ISMP is aware of an extremely hazardous packaging error involving certain cisatracurium products from Meitheal Pharmaceuticals. While the outer carton identifies the vials inside as cisatracurium, the vials contained in the carton are labeled