Root cause analysis of adverse events in an outpatient anticoagulation management consortium.
Approach to Improving Safety
Setting of Care
Anticoagulation confers a high risk of adverse drug events. Examining root cause analyses of anticoagulation–related adverse events, this study found that the majority were not preventable and were due to patient-specific issues. Unlike a prior study, researchers did not include patient perspectives in their analysis, which may have affected their conclusions.