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PSNet: Patient Safety Network
Journal Article

A visual medication schedule to improve anticoagulation control: a randomized, controlled trial.

Machtinger EL, Wang F, Chen L-L, et al. Joint Commission journal on quality and patient safety. 2007;33:625-35.

Prevention of medication errors remains a focus of patient safety efforts, with warfarin use posing unique challenges, particularly for patients. This study used a visual medication schedule at each patient visit, coupled with brief counseling, to improve the time to reach anticoagulation control. For patients with a poor understanding of their warfarin regimen, investigators discovered significant benefits from the intervention, with nearly a 2-week difference in reaching a therapeutic goal. While similar benefit did not occur in those with good understanding of their regimen and the study was not powered to determine the role of health literacy on such understanding, the authors point out the value of this simple strategy to enhance warfarin safety for at-risk patients.