Key result
Pharmacist reviews reveal drug omission drives ~27% of DOAC incidents, frequently prompting pharmacological strategy changes.
Why the study?
DOAC-related medication incidents are common, and the role of pharmacists in minimizing these incidents in hospital in-patients requires assessment using an error theory.
Population
Hospital in-patients prescribed DOACs at a large University academic hospital in the West Midlands of England (812 reports)
Comparison
Pharmacists' interventions versus medication incidents related to DOACs
Design
Observational study using incident reporting and prescribing system data with Reason's Accident Causation Model
Follow-up
48 months for incident data and 26 months for intervention data
Authors
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Active failures predominate in DOAC incidents; supports targeted prescriber education and pharmacist review but leaves open prospective validation.
Observational (n=812)
No
Prescribers' active failures, rather than system errors, contribute to the majority of DOAC-related incidents, highlighting the critical role of pharmacists in mitigating these errors through clinical checks and dose adjustments.
Haque et al. (2021) conducted an observational in DOAC-related medication incidents (n=812). Direct oral anticoagulants (DOACs) was evaluated on Frequency, type and potential causality of DOAC-related incidents. Missing drug/omission was the most common DOAC-related incident (26.6%), with 89.5% of incidents caused by active failures, while pharmacist interventions most frequently involved pharmacological strategy changes (38.1%).
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