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Margaret Fang, MD, MPH; Raman Khanna, MD, MAS; July 2011
Following hospitalization for community-acquired pneumonia, an elderly man with a history of dementia, falls, and atrial fibrillation is discharged on antibiotics but no changes to his anticoagulation medication. One week later, the patient’s INR was dangerously high.
Daner WE, Gosselin RC, Raschke R, Vanderveen T. Patient Saf Qual Healthcare. January/February 2009;6:20-25.
This article explains safety challenges commonly associated with heparin, a high-alert medication, and outlines how hospitals and clinicians can prevent these errors.