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Anticoagulants

Origin/Sponsor

•Australia and New Zealand (2)

•Central and South America (1)

•North America (64)

Resource Types

•Audiovisual (2)

•Book/Report (1)

•Clinical Guideline (1)

•Journal Article (49)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (17)

•Press Release/Announcement (2)

•Tools/Toolkit (1)

•Web Resource (2)

Error Types

•Epidemiology of Errors and Adverse Events (24)

•Active Errors (23)

•Latent Errors (8)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (21)

•Legal and Policy Approaches (6)

•Error Reporting and Analysis (26)

•Communication Improvement (17)

•Human Factors Engineering (21)

•Teamwork (1)

•Specialization of Care (15)

•Logistical Approaches (6)

•Technologic Approaches (27)

•Education and Training (12)

Clinical Areas

•Medicine (60)

•Pharmacy (30)

Target Audience

•Health Care Providers (59)

•Health Care Executives and Administrators (52)

•Non-Health Care Professionals (11)

•Patients (10)

Setting of Care

•Hospitals (55)

•Residential Facilities (6)

•Ambulatory Care (7)

•Outpatient Surgery (1)

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COMMENTARY

The Role of Bar Coding and Smart Pumps in Safety

Jeffrey M. Rothschild, MD, MPH; Carol Keohane, RN, BSN AHRQ WebM&M [serial online]. September 2008.

ORGANIZATIONAL POLICY/GUIDELINES

Preventing errors relating to commonly used anticoagulants.

Sentinel Event Alert. September 24, 2008;(41):1-4.

STUDY

Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.

Waitman LR, Phillips IE, McCoy AB, et al. Jt Comm J Qual Patient Saf. 2011;37:326-332.

NEWSPAPER/MAGAZINE ARTICLE

Officials investigate infants' heparin OD at Texas hospital.

Vonfremd M, Ibanga I. ABC News.com. July 10, 2008.

NEWSPAPER/MAGAZINE ARTICLE

Heparin overdose in three infants revisits hospital error issues.

Phend C. MedPage Today. November 26, 2007.

NEWSPAPER/MAGAZINE ARTICLE

Action needed to prevent dangerous heparin-insulin confusion.

ISMP Medication Safety Alert! Acute Care Edition. May 3, 2007;12:1-2.

STUDY

Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.

Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.

NEWSPAPER/MAGAZINE ARTICLE

Common cause analysis.

Clapper C, Crea K. Patient Saf Qual Healthc. May/June 2010;7:30-35.

NEWSPAPER/MAGAZINE ARTICLE

Anticoagulant safety practices call for pharmacist supervision.

Scott A. Drug Topics (Health-System Edition). November 10, 2008.

STUDY

Impact of a standard medication chart on prescribing errors: a before-and-after audit.

Coombes ID, Stowasser DA, Reid C, Mitchell CA. Qual Saf Health Care. 2009;18:478-485.

STUDY

Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration system.

Fitzhenry F, Doran J, Lobo B, et al. Am J Health Syst Pharm. 2011;68:434-441.

COMMENTARY

Preparing your hospital for compliance with The Joint Commission's National Patient Safety Goals.

Murdaugh L, Jordin R. Hosp Pharm. 2008;43:728-733.

STUDY

Medication error reporting in nursing homes: identifying targets for patient safety improvement.

Greene SB, Williams CE, Pierson S, Hansen RA, Carey TS. Qual Saf Health Care. 2010;19:218-222.

CLINICAL GUIDELINE classic

classic

Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association.

Michaels AD, Spinler SA, Leeper B, et al; American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology, Council on Quality of Care and Outcomes Research, Council on Cardiopulmonary, Critical Care, Perioperative, and Resuscitation, Council on Cardiovascular Nursing, Stroke Council. Circulation. 2010;121:1664-1682.

AUDIOVISUAL

Preventing fatal heparin overdoses.

Food and Drug Administration (FDA) Patient Safety News. Show #58. December 2006.

STUDY

Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts.

Miller AM, Boro MS, Korman NE, Davoren JB. J Am Med Inform Assoc. 2011;18(suppl 1):i45-i50.

COMMENTARY

Anticoagulation patient safety goal compliance at a university health system: methods for achieving the goal.

Franco AC, Maxwell P, Green K, Barthol C. Hosp Pharm. 2009;44:776-780, 784.

NEWSPAPER/MAGAZINE ARTICLE

Hospital drug errors far from uncommon.

Lin R-G II, Watanabe T. Los Angeles Times. November 22, 2007;A1.

BOOK/REPORT

Building a Memory: Preventing Harm, Reducing Risks and Improving Patient Safety.

Scobie S, Thomson R. London, England: National Patient Safety Agency; 2005.

STUDY

Contraindicated medication use in dialysis patients undergoing percutaneous coronary intervention.

Tsai TT, Maddox TM, Roe MT, et al; National Cardiovascular Data Registry. JAMA. 2009;302:2458-2464.

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