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Search results for "Anticoagulants"
Cases & Commentaries
- Spotlight Case
- Web M&M
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.
Journal Article > Review
Effectiveness of interventions designed to promote patient involvement to enhance safety: a systematic review.
Hall J, Peat M, Birks Y, Golder S; on behalf of the PIPS Group. Qual Saf Health Care. 2010;19:e10.
This systematic review found limited evidence linking engagement of patients in safety to improved safety or clinical outcomes, with the exception of programs to encourage self-management of oral anticoagulants.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. September 24, 2008;(41):1-4.
Anticoagulant therapies such as heparin and warfarin are considered high-alert medications, due to the high potential for patient harm if used improperly. They have been associated with adverse events in a variety of settings, including in hospitalized patients and outpatients, and ensuring the safety of patients receiving anticoagulants is a National Patient Safety Goal for 2008. This sentinel event alert issued by the Joint Commission discusses the root causes of anticoagulant-associated patient harm and recommends strategies for reducing errors, including implementation of a pharmacist-led anticoagulation service. Sentinel event alerts are intended to promote rapid implementation of patient safety strategies, and adherence to these recommendations is assessed on site visits by the Joint Commission.
Journal Article > Study
The importance of establishing regimen concordance in preventing medication errors in anticoagulant care.
Schillinger D, Wang F, Rodriguez M, Bindman A, Machtinger EL. J Health Comm. 2006;11:555-567.
The researchers examined patient adherence to a warfarin regimen and concordance between the patient's regimen and physician's report. They found that miscommunication may contribute to under- and overanticoagulation.
Journal Article > Review
Sharma AE, Rivadeneira NA, Barr-Walker J, Stern RJ, Johnson AK, Sarkar U. Health Aff (Millwood). 2018;37:1813-1820.
Patient and family engagement efforts can affect health care quality and safety. This review examined the research on patient engagement efforts and found evidence of robust examinations of patient engagement related to patient self-management of anticoagulation medications. However, there was mixed-quality evidence on patient involvement in medication administration errors, documentation and scheduling accuracy, hospital readmissions, and health care–associated infections. They recommend areas of research needed to guide the application of patient engagement strategies.