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Search results for "Anticoagulants"
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Journal Article > Study
Piazza G, Nguyen TN, Cios D, et al. Am J Med. 2011;124:1136-1142.
Warfarin and other anticoagulant medications place patients, especially elderly ones, at high risk of adverse drug events (ADEs) due to their narrow therapeutic window. This retrospective analysis of anticoagulant-related ADEs at an academic medical center identified the underlying cause of these events and found evidence that a large proportion should be preventable. More than two-thirds of anticoagulant-related ADEs were attributable to medication errors, usually at the medication administration stage. A large proportion of the errors were ascribed to incorrect transcription of orders. The persistent incidence of transcription errors in this study is especially surprising given that the hospital in question already had a computerized provider order entry (CPOE) system. Fully electronic closed-loop medication systems, which integrate CPOE, barcoding, and electronic medication administration records, hold promise as a means of reducing both transcribing and administration errors.
Legislation/Regulation > Multi-use Website
Oakbrook Terrace, IL: The Joint Commission; 2018.
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, and specific clinical harms such as falls and pressure ulcers. The 2019 NPSGs include two significant revisions. Hospitals and behavioral health facilities now must maintain specific protocols to prevent inpatient suicide, including conducting environmental risk assessments, screening patients admitted for behavioral health reasons for suicide risk, and implementing tailored suicide prevention plans for high-risk patients. The NPSG on ensuring the safety of anticoagulant medications has also been updated to incorporate new evidence in this area.