U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality: Advancing Excellence in Health Care
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Rockville, MD: Agency for Healthcare Research and Quality, August 2010. AHRQ Publication No. 09-0086-C.
This guide provides information for consumers taking the blood thinner, warfarin.
Translating From Normal to Abnormal
Anne M. Turner, MD, MLIS, MPH
ASH Clinical Practice Guidelines on Venous Thromboembolism.
Washington, DC: American Society of Hematology; 2018.
Direct oral anticoagulants: a review of common medication errors.
Barr D, Epps QJ. J Thromb Thrombolysis. 2019;47:146-154.
Anticoagulant medication errors in hospitals and primary care: a cross-sectional study.
Dreijer AR, Diepstraten J, Bukkems VE, et al. Int J Qual Health Care. 2018 Aug 25; [Epub ahead of print].
Defining minimum necessary anticoagulation-related communication at discharge: Consensus of the Care Transitions Task Force of the New York State Anticoagulation Coalition.
Triller D, Myrka A, Gassler J, et al. Jt Comm J Qual Patient Saf. 2018;44:630-640.
Root cause analysis of adverse events in an outpatient anticoagulation management consortium.
Graves CM, Haymart B, Kline-Rogers E, et al. Jt Comm J Qual Patient Saf. 2017;43:299-307.
Reducing error in anticoagulant dosing via multidisciplinary team rounding at point of care.
Sharma M, Krishnamurthy M, Snyder R, Mauro J. Clin Pract. 2017;7:953.
2017 ISMP Medication Safety Self Assessment® for Antithrombotic Therapy in Hospitals.
Horsham, PA: Institute for Safe Medication Practices; 2017.
Request for comments on the proposed measures and 2020 targets for the National Action Plan for Adverse Drug Event Prevention: inpatient and outpatient measures for reduction of adverse drug events from anticoagulants, diabetes agents, and opioid analgesics.
Federal Register. Washington, DC: Office of Disease Prevention and Health Promotion, US Department of Health and Human Services. October 20, 2016;81:72594-72595.
Inappropriate preinjury warfarin use in trauma patients: a call for a safety initiative.
Hon HH, Elmously A, Stehly CD, et al. J Postgrad Med. 2016;62:73-79.
An observational study of direct oral anticoagulant awareness indicating inadequate recognition with potential for patient harm.
Olaiya A, Lurie B, Watt B, McDonald L, Greaves M, Watson HG. J Thromb Haemost. 2016;14:987-990.
Direct oral anticoagulants: new drugs with practical problems. How can nurses help prevent patient harm?
Barras MA, Hughes D, Ullner M. Nurs Health Sci. 2016;18:408-411.
Predictors of warfarin-associated adverse events in hospitalized patients: opportunities to prevent patient harm.
Metersky ML, Eldridge N, Wang Y, et al. J Hosp Med. 2016;11:276-282.
Improving transitions of care for patients on warfarin: the Safe Transitions Anticoagulation Report.
Dunn AS, Shetreat-Klein A, Berman J, et al. J Hosp Med. 2015;10:615-618.
Popular blood thinner causing deaths, injuries in nursing homes.
Ornstein C. Washington Post. July 12, 2015.
Heparin-containing medical devices and combination products: recommendations for labeling and safety testing. Draft guidance for industry and Food and Drug Administration staff.
Federal Register. Washington, DC: US Department of Health and Human Services. Baltimore, MD: Food and Drug Administration. July 9, 2015;80:39440-39441.
Anticoagulant medication errors in nursing homes: characteristics, causes, outcomes, and association with patient harm.
Desai RJ, Williams CE, Greene SB, Pierson S, Hansen RA. J Healthc Risk Manag. 2013;33:33-43.
Delivery of optimized inpatient anticoagulation therapy: consensus statement from the Anticoagulation Forum.
Nutescu EA, Wittkowsky AK, Burnett A, Merli GJ, Ansell JE, Garcia DA. Ann Pharmacother. 2013;47:714-724.
Dementia and risk of adverse warfarin-related events in the nursing home setting.
Tjia J, Field TS, Mazor KM, et al. Am J Geriatr Pharmacother. 2012;10:323-330.
Anticoagulation-associated adverse drug events.
Piazza G, Nguyen TN, Cios D, et al. Am J Med. 2011;124:1136-1142.
Provider and pharmacist responses to warfarin drug–drug interaction alerts: a study of healthcare downstream of CPOE alerts.
Miller AM, Boro MS, Korman NE, Davoren JB. J Am Med Inform Assoc. 2011;18(suppl 1):i45-i50.
Novel analysis of clinically relevant diagnostic errors in point-of-care devices.
Shermock KM, Streiff MB, Pinto BL, Kraus P, Pronovost PJ. J Thromb Haemost. 2011;9:1769-1775.
Adopting real-time surveillance dashboards as a component of an enterprisewide medication safety strategy.
Waitman LR, Phillips IE, McCoy AB, et al. Jt Comm J Qual Patient Saf. 2011;37:326-332.
Clinical and safety impact of an inpatient pharmacist-directed anticoagulation service.
Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.
MGH faces suit over drug error that killed woman.
Valencia MJ. Boston Globe. March 10, 2011.
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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