Impact of a pharmacist‐to‐dose direct oral anticoagulant protocol on medication errors at an academic medical center

Abstract Background Direct oral anticoagulants (DOACs) are considered high‐risk medications and pose a serious threat to patients if mismanaged. Furthermore, medication error rates involving DOACs in the acute care setting range from 25% to 40%. To reduce medication error rates at our institution, we implemented a pharmacist‐driven DOAC protocol that permitted pharmacists to independently order and monitor DOACs pursuant to a consult order. Objective To determine the impact of a pharmacist‐to‐dose DOAC protocol on medication errors at an academic medical center. Methods This was a retrospective, single‐center cohort study using a pre‐post design to evaluate the impact of a pharmacist‐to‐dose DOAC protocol on rates of medication errors. Patient data were evaluated during a 6‐month period before and after the implementation of the protocol. Patients were excluded if they were receiving a DOAC for an indication other than venous thromboembolism and/or atrial fibrillation. Results A total of 502 patients (pre‐phase = 256; post‐phase = 246) admitted to the hospital and receiving a DOAC were included in the study. A total of 41 patients in the pre‐phase received a medication error involving a DOAC compared with 22 patients in the post‐phase (16% vs 8.9%; relative risk reduction 44%; P = .017). Rates of near misses were numerically higher in the post‐phase group (7.4% vs 11.8%; P = .1), and rates of discharge DOAC errors were numerically lower (8.5% vs 4.9%; P = .1). The most common error was underdosing (N = 31). Conclusion In this study, the implementation of a pharmacist‐to‐dose DOAC protocol was associated with a 44% reduction in DOAC‐related medication errors. These findings underscore the impact of a protocolized approach to DOAC management, as well as the role of pharmacists in overseeing inpatient DOAC use and reducing medication errors.