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The medication-use process is highly complex with many steps and risk points for error, and those errors are a key target for improving safety. This Library reflects a curated selection of PSNet content focused on medication and drug errors. Included resources explore understanding harms from preventable medication use, medication safety improvement strategies, and resources for design.

Al Rowily A, Jalal Z, Price MJ, et al. Eur J Clin Pharmacol. 2021;Epub Dec 22.
Although direct acting oral anticoagulants (DAOCs) are generally considered safer than older anticoagulants, they are still high-risk medications. This review found that between 5.3% and 37.3% of patients experienced either a prescription, administration, or dosing error. Prescribing errors constituted the majority of error types, and common causes were active failures, including wrong drug or wrong dose.
Haque H, Alrowily A, Jalal Z, et al. Int J Clin Pharm. 2021;43(6):1693-1704.
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.
Attia E, Fuentes A, Vassallo M, et al. Am J Health Syst Pharm. 2021;Epub Nov 2.
Anti-coagulants are classified as high-risk medications due to their potential to cause serious patient harm if not administered correctly. This hospital created a multidisciplinary anticoagulant safety taskforce to reduce errors and improve patient safety. The article describes the implementation process, including the use of the 2017 Institute for Safe Medication Practices (ISMP) Medication Safety Self-Assessment for Antithrombotic Therapy tool.
The Joint Commission.
The National Patient Safety Goals (NPSGs) are one of the major methods by which The Joint Commission establishes standards for ensuring patient safety in all health care settings. In order to ensure health care facilities focus on preventing major sources of patient harm, The Joint Commission regularly revises the NPSGs based on their impact, cost, and effectiveness. Major focus areas include promoting surgical safety and preventing hospital-acquired infections, medication errors, inpatient suicide, and specific clinical harms such as falls and pressure ulcers. 
Slikkerveer M, van de Plas A, Driessen JHM, et al. J Patient Saf. 2021;17(7):e587-e592.
Anticoagulants, such as low-molecular-weight heparin (LMWH), are known to be high-risk for adverse drug events. This cross-sectional study identified prescribing errors – primarily lack of dosage adjustment for body weight and/or renal function – among one-third of LMWH users admitted to one hospital over a five-month period.
Sugrue A, Sanborn D, Amin M, et al. Am J Cardiol. 2020;144:52-59.
Anticoagulants are common medications that carry the potential for serious harm if administered incorrectly. This retrospective review of 8,576 patients with atrial fibrillation who received direct oral anticoagulants identified inappropriate dosing in nearly 15% of cases, with most patients receiving an inappropriately low dose. Over one year of follow-up, the authors did not identify any significant difference in the incidence of stroke, embolism, bleeding, or ischemic attacks between patients who were inappropriately, versus appropriately, dosed.
Cattaneo D, Pasina L, Maggioni AP, et al. Drugs Aging. 2021;38(4):341-346.
Older adults are at increased risk of hospitalization due to COVID-19 infections. This study examined the potential severe drug-drug interactions (DDI) among hospitalized older adults taking two or more medications at admission and discharge. There was a significant increase in prescription of proton pump inhibitors and heparins from admission to discharge. Clinical decision support systems should be used to assess potential DDI with particular attention paid to the risk of bleeding complications linked to heparin-based DDIs.
Gurwitz JH, Kapoor A, Garber L, et al. JAMA Intern Med. 2021;181(5):610-618.
High-risk medications have the potential to cause serious patient harm if not administered correctly. In this randomized trial, a pharmacist-directed intervention (including in-home assessment by a clinical pharmacist, communication with the primary care team, and telephone follow-up) did not result in a lower rate of adverse drug events or medication errors involving high-risk drug classes during the posthospitalization period.

A 60-year-old male presented to the emergency department (ED) with his partner after an episode of dizziness and syncope when exercising. An electrocardiogram demonstrated non-ST-elevation myocardial infarction abnormalities. A brain CT scan was ordered but the images were not assessed prior to initiation of anticoagulation treatment. While awaiting further testing, the patient’s heart rate slowed and a full-body CT scan demonstrated an intracranial hemorrhage. An emergent craniotomy was performed and the patient later died.

Farnborough, UK; Healthcare Safety Investigation Branch. October 13, 2020

Errors of omission in routine care can result in patient harm. This report discusses factors contributing to a pulmonary embolism in a recovering stroke patient acerbated by a lack of intended but omitted venous thromboembolism or VTE preventative care. The system improvement recommendations drawn from the incident analysis include that the UK National Health Service develop a standardized approach to VTE risk assessment and broad-based training to enable a cross-section of clinicians to use VTE prevention devices as required.

Farnborough, UK: Healthcare Safety Investigation Branch; September 24, 2020. 

Unit-based pharmacy services help to mitigate and catch medication errors. This report highlights a case of a medication error death and describes how embedding clinical pharmacy services could have prevented this incident. The report provides system level recommendations to enhance this service including defining the role of clinical pharmacy teams and prioritizing the tactic as an important improvement strategy.   

ISMP Medication Safety Alert! Acute Care Edition. May 22, 2020;25(10).

Smart infusion pumps are widely used in hospitals to reduce medication errors but have the potential to create problems if not correctly used. This article discusses heparin administration programming errors and recommends independent double-checks, electronic health record and smart pump interoperability and weight-based dosing as tactics to minimize mistakes.   
Austin J, Barras M, Sullivan C. Int J Med Inform. 2020;135.
The authors systematically reviewed the evidence on electronic health record (EHR) interventions designed to improve the safety and quality of anticoagulation administration in inpatient hospitals settings. The 27 articles meeting inclusion criteria examined four types of interventions: computerized physician order entry (CPOE), clinical decision support systems (CDSS), dashboards, and general EHR implementation. Included studies reported reductions in medication errors and adverse drug events with use of CPOE and CDDS, but studies did not find benefits to other adverse events (e.g., bleeding events), readmissions or length of stay. Overall, the review found limited evidence demonstrating the benefit of inpatient EHR interventions in improving anticoagulation safety and quality.
Leguelinel-Blache G, Castelli C, Rolain J, et al. Expert Rev Pharmacoecon Outcomes Res. 2020;20(5):481-490.
The value of medication reviews in reducing adverse drug events (ADEs) is now generally accepted although robust evidence of cost or clinical effectiveness of such reviews is lacking. For this pilot study of patients in a French nursing home, ADE risk scores were calculated before and six months after a pharmacist-led multidisciplinary review of each patient’s medications. Significant drops in ADE risk scores, as well as reductions in the number of patients taking at least one potentially inappropriate medication and substantial cost savings for the nursing home, are reported in this preliminary assessment.
Pino FA, Weidemann DK, Schroeder LL, et al. Am J Health Syst Pharm. 2019;76(23):1972-1979.
Heparin – a commonly used anticoagulant – is a high-risk medication and a patient safety risk to both adults and children. This study used a failure mode and effects analysis (FMEA) to prospectively analyze various steps in the preparation, use and disposal of heparin in a pediatric hospital to identify areas of improvement. The FMEA identified 233 potential failures and 737 potential causes of failure. Underlying causes of failure included mathematical errors, EHR challenges, and varying practice and operating procedures (or lack thereof). Countermeasures to address underlying causes are also addressed.
Frazer A, Rowland J, Mudge A, Barras M, Martin J, Donovan P. Systematic review of interventions to improve safety and quality of anticoagulant prescribing for therapeutic indications for hospital inpatients. Eur J Clin Pharmacol. 2019;75(12):1645-1657.
Adverse drug events associated with anticoagulation medications are common in hospitalized patients. This study comprises a systematic review and meta-analysis of 19 trials of controlled, system-level interventions (evaluating 12,742 patients) for improving the safety or quality of anticoagulant prescribing for hospitalized adults. Due to insufficient high-quality evidence, no reviewed intervention could be recommended, although some interventions merit further evaluation such as anticoagulation consultation services and decision supported warfarin dosing. The authors conclude that additional adequately powered, controlled trials—especially of interventions designed to ensure safe prescribing of low molecular weight heparins and direct acting oral anticoagulants—are needed.   
Following resection of colorectal cancer, a hospitalized elderly man experienced a pulmonary embolism, which was treated with rivaroxaban. Upon discharge home, he received two separate prescriptions for rivaroxaban (per protocol): one for 15 mg twice daily for 10 days, and then 20 mg daily after that. Ten days later, the patient's wife returned to the pharmacy requesting a refill. On re-reviewing the medications with her, the pharmacist discovered the patient had been taking both prescriptions (a total daily dose of 50 mg daily).

Sentinel Event Alert. July 30, 2019;(61):1-5.

Anticoagulant medications are known to be high-risk for adverse drug events. Although direct oral anticoagulants (DOACs) require less monitoring than warfarin, they are still associated with an increased risk of patient harm if not prescribed and administered correctly. The Joint Commission has issued a new sentinel event alert to raise awareness of the risks related to DOACs, and in particular, the challenges associated with stopping bleeding in patients on these medications. The alert suggests that health care organizations develop patient education materials, policies, and evidence-based guidelines to ensure that DOACs and reversal agents are used appropriately. A past WebM&M commentary discussed common errors related to the use of DOACs.