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Washington, DC: American Society of Hematology; 2018.
The American Society of Hematology released new guidelines on prophylaxis for venous thromboembolism, which can be a patient safety problem among hospitalized patients. Key recommendations include low-molecular-weight heparin as the preferred agent when medication prophylaxis is indicated and screening of all hospitalized patients for venous thromboembolism risk and bleeding.
Ornstein C. Washington Post. July 12, 2015.
Anticoagulants are considered high-alert medications that if used ineffectively can result in patient harm. Reporting on an anticoagulant commonly used in nursing homes and patient harm linked to this medication, this newspaper article relates reasons doctors are reluctant to prescribe new drugs to older patients and challenges to monitoring and preventing such adverse drug events.
Journal Article > Study
Schillig J, Kaatz S, Hudson M, Krol GD, Szandzik EG, Kalus JS. J Hosp Med. 2011;6:322-328.
Patients receiving warfarin therapy are at high risk for adverse events. Interventions to improve warfarin safety have focused on trigger tools, communication protocols, and the use of visual medication schedules. This study implemented a pharmacist-directed anticoagulation service to capture inpatients on warfarin and provide them with dosing, monitoring, and coordination of transition from the inpatient to outpatient setting. This cluster randomized trial demonstrated safer transitions in 73% more patients and a 32% reduction in the composite safety end point, which was driven by fewer patients experiencing an INR ≥ 5 (i.e., supratherapeutic levels that increase the risk of bleeding). This study adds further support to the role of pharmacists in driving medication safety, specifically for warfarin in both the inpatient and community settings. A past AHRQ WebM&M commentary discussed a case of a near miss due to a warfarin drug interaction that led to a supratherapeutic level following hospital discharge.
Journal Article > Study
Medication-error alerts for warfarin orders detected by a bar-code-assisted medication administration system.
Fitzhenry F, Doran J, Lobo B, et al. Am J Health Syst Pharm. 2011;68:434-441.
The vast majority of warnings about warfarin (a commonly prescribed anticoagulant) generated by a bar-code medication administration system were clinically insignificant.