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Anticoagulants

Origin/Sponsor

•Australia and New Zealand (2)

•Central and South America (1)

•North America (30)

Resource Types

•Audiovisual (1)

•Clinical Guideline (2)

•Journal Article (30)

•Legislation/Regulation (1)

•Newspaper/Magazine Article (4)

•Press Release/Announcement (1)

Error Types

•Epidemiology of Errors and Adverse Events (12)

•Active Errors (16)

•Latent Errors (6)

•Near Miss (1)

Approach to Improving Safety

•Quality Improvement Strategies (14)

•Legal and Policy Approaches (2)

•Error Reporting and Analysis (8)

•Communication Improvement (13)

•Human Factors Engineering (13)

•Specialization of Care (7)

•Logistical Approaches (4)

•Technologic Approaches (16)

•Education and Training (7)

Clinical Areas

•Medicine (37)

•Pharmacy (14)

Target Audience

•Health Care Providers (34)

•Health Care Executives and Administrators (26)

•Non-Health Care Professionals (5)

•Patients (1)

Setting of Care

•Hospitals (25)

•Residential Facilities (1)

•Ambulatory Care (3)

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COMMENTARY

Surprise Wire

Pearl JM, Donaldson NE. AHRQ WebM&M [serial online]. July/August 2005.

COMMENTARY

Bleeding Risk.

Crowther MA. AHRQ WebM&M [serial online]. July 2003.

STUDY

Emergency department visits for outpatient adverse drug events: demonstration for a national surveillance system.

Budnitz DS, Pollock DA, Mendelsohn AB, Weidenbach KN, McDonald AK, Annest JL. Ann Emerg Med. 2005;45:197-206.

STUDY

The importance of establishing regimen concordance in preventing medication errors in anticoagulant care.

Schillinger D, Wang F, Rodriguez M, Bindman A, Machtinger EL. J Health Comm. 2006;11:555-567.

COMMENTARY

Crossed Coverage

Kayser SR. AHRQ WebM&M [serial online]. February 2007.

STUDY

Error in body weight estimation leads to inadequate parenteral anticoagulation.

Dos Reis Macedo LG, de Oliveira L, Pintão MC, Garcia AA, Pazin-Filho A. Am J Emerg Med. 2011;29:613-617.

COMMENTARY

Hold the tPA.

Fagan SC. AHRQ WebM&M [serial online]. April 2005.

COMMENTARY

ISMP medication error report analysis.

Cohen MR. Hosp Pharm. 2005;40:556-557.

NEWSPAPER/MAGAZINE ARTICLE

Patient safety records: silent witness.

Gould M. Health Service Journal. September 15, 2008:22-24.

STUDY

Relationship of incorrect dosing of fibrinolytic therapy and clinical outcomes.

Mehta RH, Alexander JH, Van de Werf F, et al. JAMA. 2005;293:1746-1750.

STUDY

Effectiveness of a computerized system for intravenous heparin administration: using information technology to improve patient care and patient safety.

Oyen LJ, Nishimura RA, Ou NN, Armon JJ, Zhou M. Am Heart Hosp J. 2005;3:75-81.

STUDY

Excess dosing of antiplatelet and antithrombin agents in the treatment of non–ST-segment elevation acute coronary syndromes.

Alexander KP, Chen AY, Roe MT, et al; CRUSADE Investigators. JAMA. 2005;294:3108-3116.

COMMENTARY

Around the Block.

Minichiello T. AHRQ WebM&M [serial online]. March 2005.

COMMENTARY

Unreported errors in the intensive care unit: a case study of the way we work.

Henneman EA. Crit Care Nurse. 2007;27:27-34.

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

Potentially unintended discontinuation of long-term medication use after elective surgical procedures.

Bell CM, Bajcar J, Bierman AS, et al. Arch Intern Med. 2006;166:2525-2531.

COMMENTARY

2009 National Patient Safety Goals.

Saufl NM. J Perianesth Nurs. 2009;24:114-118.

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.

COMMENTARY

Hidden Heparins: HIT Happens

Fogarty PF. AHRQ WebM&M [serial online]. December 2006.

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