Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory.

Hazera Haque; Abdulrhman Alrowily; Zahraa Jalal; Bijal Tailor; Vicky Efue; Asif Sarwar; Vibhu Paudyal

Study

Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory.

December 22, 2021

Haque H, Alrowily A, Jalal Z, et al. Int J Clin Pharm. 2021;43(6):1693-1704.

View more articles from the same authors.

While direct oral anticoagulants (DOAC) are considered safer than warfarin, DOAC-related medication errors still occur. This study assesses the frequency, type, and potential causality of DOAC-related medication errors and the nature of clinical pharmacist intervention. Active, rather than latent, failures contributed to most errors.

PubMed citation

Free full text

Related Resources From the Same Author(s)

Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis.

January 12, 2022

Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the national reporting and learning system.

July 12, 2023

Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies.

December 1, 2021

Medication reconciliation in the geriatric unit: impact on the maintenance of post-hospitalization prescriptions.

October 13, 2021

Evaluation of the quality of 'do not use' medication abbreviation audits: a key enabler to successful implementation of audit and feedback.

March 24, 2021

Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis.

October 14, 2020

Potentially inappropriate prescribing for adults living with diabetes mellitus: a scoping review.

October 5, 2022

Risk factors for clinically relevant deviations in patients' medication lists reported by patients in personal health records: a prospective cohort study in a hospital setting.

March 2, 2022

Direct oral anticoagulants: a review of common medication errors.

November 21, 2018

Correlation between the number of patient-reported adverse events, adverse drug events, and quality of life in older patients: an observational study.

November 2, 2022

Patient Safety Innovations

Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies.

April 7, 2022

March 16, 2022

Impact of computerised physician order entry (CPOE) on the incidence of chemotherapy-related medication errors: a systematic review.

April 7, 2021

A qualitative study of prescribing errors among multi-professional prescribers within an e-prescribing system.

December 23, 2020

How do hospital inpatients conceptualise patient safety? A qualitative interview study using constructivist grounded theory.

October 19, 2022

Older patients' engagement in hospital medication safety behaviours.

June 16, 2021

Inappropriate dosing of direct oral anticoagulants in patients with atrial fibrillation.

April 28, 2021

A randomized clinical trial to compare the use of safety net enclosures with standard restraints in agitated hospitalized patients.

January 9, 2008

The impact of an electronic alert to reduce the risk of co-prescription of low molecular weight heparins and direct oral anticoagulants.

July 6, 2022

Assessment of requests for medication-related follow-up after hospital discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart review.

December 8, 2021

Hospitalizations and deaths related to adverse drug events worldwide: systematic review of studies with national coverage.

May 25, 2022

Evaluation of medication incidents in a long-term care facility using electronic medication administration records and barcode technology.

October 5, 2022

Errors in adult trauma resuscitation: a systematic review.

June 30, 2021

Factors influencing providers' willingness to deprescribe medications.

December 1, 2021

Medication incident recovery and prevention utilising an Australian community pharmacy incident reporting system: the QUMwatch study.

May 5, 2021

Pharmacist-led intervention on the reduction of inappropriate medication use in patients with heart failure: a systematic review of randomized trials and non-randomized intervention studies.

August 18, 2021

Hospital quality-review spending and patient safety: a longitudinal analysis using instrumental variables.

July 7, 2021

Prevalence, nature, severity and preventability of adverse drug events in mental health settings: findings from the MedicAtion relateD harm in mEntal health hospitals (MADE) study.

August 11, 2021

Establishing a multidisciplinary taskforce to improve anticoagulation safety at a large health system.

December 12, 2021

Reducing risks in complex care transitions in rural areas: a grounded theory.

March 22, 2023

Recognition of adverse drug events in older hospitalized medical patients.

July 11, 2012

Drug-drug interactions and prescription appropriateness at hospital discharge: experience with COVID-19 patients.

April 21, 2021

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

March 7, 2012

Prescribers' perspectives on including reason for use information on prescriptions and medication labels: a qualitative thematic analysis.

March 10, 2021

Testimonial injustice: linguistic bias in the medical records of black patients and women.

June 6, 2021

Effect of pharmacist counseling intervention on health care utilization following hospital discharge: a randomized control trial.

June 8, 2016

Influence of opioid prescription policy on overdoses and related adverse effects in a primary care population.

May 19, 2021

Evaluation of older persons' medications: a critical incident technique study exploring healthcare professionals' experiences and actions.

June 23, 2021

Remember that patient you saw last week: characteristics and frequency of patients experiencing anticipated and unanticipated death following ED discharge.

December 1, 2021

Increased patient safety-related incidents following the transition into Daylight Savings Time.

September 9, 2020

Identification of common themes from never events data published by NHS England.

April 14, 2021

State medical board regulation of compounding in physician offices.

June 9, 2021

Medication errors in community pharmacies: evaluation of a standardized safety program.

March 15, 2023

There's no place like home--integrating a pharmacist into the hospital-in-home model.

March 17, 2021

The impact of medication reconciliation and review in patients using oral chemotherapy.

March 1, 2023

Hospital inpatient falls across clinical departments.

September 1, 2021

A human factors intervention in a hospital--evaluating the outcome of a TeamSTEPPS program in a surgical ward.

April 14, 2021

Including the reason for use on prescriptions sent to pharmacists: scoping review.

January 26, 2022

Multifactorial interventions to reduce duration and variability in delays to identification of serious injury after falls in hospital inpatients.

April 27, 2022

Avoiding a Med-Wreck: a structured medication reconciliation framework and standardized auditing tool utilized to optimize patient safety and reallocate hospital resources.

March 3, 2021

Comprehensive evaluation of using computerised provider order-entry system for hospital discharge orders.

May 4, 2022

Training in safe opioid prescribing and treatment of opioid use disorder in internal medicine residencies: a national survey of program directors.

October 12, 2022

Analysis of iatrogenic and in-hospital medication errors reported to United States poison centers: a retrospective observational study.

June 24, 2020

Analysis of pharmacist-identified medication-related problems at two United Kingdom hospitals: a prospective observational study.

March 18, 2020

Effect of a multifaceted clinical pharmacist intervention on medication safety after hospitalization in persons prescribed high-risk medications: a randomized clinical trial.

March 17, 2021

Clinical reasoning in dire times- analysis of cognitive biases in clinical cases during the COVID-19 pandemic.

February 23, 2022

Hospital acquired infections in surgical patients: impact of COVID-19-related infection prevention measures.

April 20, 2022

Prevalence and nature of medication errors and medication-related harm following discharge from hospital to community settings: a systematic review.

July 22, 2020

Aligning patient safety and stewardship: a harm reduction strategy for children.

December 22, 2021

Medication safety at the interface: evaluating risks associated with discharge prescriptions from mental health hospitals.

January 20, 2016

Associations of person-related, environment-related and communication-related factors on medication errors in public and private hospitals: a retrospective clinical audit.

November 17, 2021

Care coordination strategies and barriers during medication safety incidents: a qualitative, cognitive task analysis.

March 10, 2021

Longitudinal medication reconciliation at hospital admission, discharge and post-discharge.

August 26, 2020

Workforce planning and safe workload in sterile compounding hospital pharmacy services.

November 24, 2021

Improving medical residents’ self-assessment of their diagnostic accuracy: does feedback help?

February 2, 2022

Developing and aligning a safety event taxonomy for inpatient psychiatry.

July 13, 2022

The development and piloting of the Ambulatory Electronic Health Record Evaluation Tool: lessons learned.

March 17, 2021

To expand the evidence base about harms from tests and treatments.

September 15, 2021

Scoping review of studies evaluating frailty and its association with medication harm.

June 22, 2022

The abrupt expansion of ambulatory telemedicine: implications for patient safety.

February 9, 2022

The efficacy of mindful practice in improving diagnosis in healthcare: a systematic review and evidence synthesis.

October 13, 2021

Use of patient complaints to identify diagnosis-related safety concerns: a mixed-method evaluation.

March 3, 2021

Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk.

November 11, 2020

Reporting of health information technology system-related patient safety incidents: the effects of organizational justice.

October 6, 2021

Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review.

February 14, 2024

Patient Safety Innovations

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

April 7, 2022

Effectiveness of a ‘do not interrupt’ vest intervention to reduce medication errors during medication administration: a multicenter cluster randomized controlled trial.

October 13, 2021

Artificial intelligence for identifying the prevention of medication incidents causing serious or moderate harm: an analysis using incident reporters' views.

November 24, 2021

Health care workers' experiences of workplace incidents that posed a risk of patient and worker injury: a critical incident technique analysis.

July 14, 2021

Observational evidence of the prevalence and association of polypharmacy and drug administration errors in hospitalized adult patients.

May 18, 2022

August 19, 2020

Changes to primary care delivery during the COVID-19 pandemic and perceived impact on medication safety: a survey study.

June 29, 2022

Medication errors related to computerized provider order entry systems in hospitals and how they change over time: a narrative review.

March 10, 2021

We asked the experts: the WHO Surgical Safety Checklist and the COVID-19 pandemic: recommendations for content and implementation adaptations.

March 17, 2021

Medication use evaluation of high-dose long-term opioid de-prescribing in multiple Veterans Affairs medical centers.

January 18, 2023

The critical role of health information technology in the safe integration of behavioral health and primary care to improve patient care.

November 10, 2021

Measuring and improving diagnostic safety in primary care: addressing the “twin” pandemics of diagnostic error and clinician burnout.

March 3, 2021

Development of the Leapfrog Group's bar code medication administration standard to address hospital inpatient medication safety.

September 21, 2022

Adverse health events related to self-medication practices among elderly: a systematic review.

May 31, 2017

Influence of a general practice pharmacist on medication management for patients at risk of medicine-related harm: a qualitative evaluation.

July 20, 2022

Video-based communication assessment of physician error disclosure skills by crowdsourced laypeople and patient advocates who experienced medical harm: reliability assessment with generalizability theory.

May 18, 2022

Avoiding a second wave of medical errors: the importance of human factors in the context of a pandemic.

August 26, 2020

ISMP medication error report analysis.

October 29, 2008

Improved medication management with introduction of a perioperative and prescribing pharmacist service.

August 12, 2020

Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.

May 12, 2021

Radiologist errors by modality, anatomic region, and pathology for 1.6 million exams: what we have learned.

March 2, 2022

Implementing a bar-code medication administration system.

January 21, 2009

ISMP medication error report analysis.

May 7, 2008

Clinical and economic impacts of explicit tools detecting prescribing errors: a systematic review.

May 26, 2021

Medication safety in mental health hospitals: a mixed-methods analysis of incidents reported to the National Reporting and Learning System.

August 4, 2021

Related Resources

Implement strategies to prevent persistent medication errors and hazards: 2024.

April 3, 2024

WebM&M Cases

Medication Mix-Up Leads to Patient Death

November 30, 2023

Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge medication reconciliation tool.

November 29, 2023

Pharmacy-led medication reconciliation is best practice.

October 11, 2023

Medication reconciliation for patients after their discharge from intensive care unit to the hospital ward.

July 19, 2023

Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the national reporting and learning system.

July 12, 2023

WebM&M Cases

The Danger of 10% Intravenous Calcium Chloride Extravasation.

April 26, 2023

Journal Article

Study

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

March 29, 2023

Survey results from pharmacists provide support to enhance the organizational response to codes.

October 26, 2022

A health system that won't learn from its mistakes.

September 21, 2022

Free-text computerized provider order entry orders used as workaround for communicating medication information.

August 31, 2022

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study.

August 24, 2022

The impact of an electronic alert to reduce the risk of co-prescription of low molecular weight heparins and direct oral anticoagulants.

July 6, 2022

Pharmacist transition-of-care services improve patient satisfaction and decrease hospital readmissions.

March 30, 2022

Sources of medication omissions among hospitalized older adults with polypharmacy.

March 9, 2022

Pharmacy Education and Practice.

January 26, 2022

Enhancing high alert medication knowledge among pharmacy, nursing, and medical staff.

June 2, 2021

In the eye of the storm: the role of the pharmacist in medication safety during the COVID-19 pandemic at an urban teaching hospital.

December 23, 2020

Longitudinal medication reconciliation at hospital admission, discharge and post-discharge.

August 26, 2020

A clinical pharmacist-led integrated approach for evaluation of medication errors among medical intensive care unit patients.

August 19, 2020

Implementation and sustainability of a medication reconciliation toolkit: a mixed methods evaluation.

August 5, 2020

Impact of structured interdisciplinary bedside rounding on patient outcomes at a large academic health centre.

July 22, 2020

Global drug shortages due to COVID-19: impact on patient care and mitigation strategies.

July 8, 2020

WebM&M Cases

When the Indications for Drug Administration Blur

June 24, 2020

Subtherapeutic heparin infusions: is your organization at risk of bypassing soft low-dose alerts?

June 3, 2020

Harm prevalence due to medication errors involving high-alert medications: a systematic review

May 20, 2020

Analysis of pharmacist-identified medication-related problems at two United Kingdom hospitals: a prospective observational study.

March 18, 2020

Preventing errors with high-risk medications.

August 28, 2019

Development and performance evaluation of the Medicines Optimisation Assessment Tool (MOAT): a prognostic model to target hospital pharmacists' input to prevent medication-related problems.

July 31, 2019

Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care.

June 28, 2017

See More About The Topic

Hospitals

Hospital Medicine

Hospital Pharmacy

Specific to High-Risk Drugs

Anticoagulants

Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory.

Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Direct oral anticoagulant-related medication incidents and pharmacists' interventions in hospital in-patients: evaluation using Reason's accident causation theory.

Assessing the impact of virtual medication history technicians on medication reconciliation discrepancies.

Pharmacist-led mobile health intervention and transplant medication safety: a randomized controlled clinical trial.

Implementation of a medication reconciliation risk stratification tool integrated within an electronic health record: a case series of three academic medical centers.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site