ABSTRACT
Anticoagulation in hospitalized patients is frequently associated with medication errors. To determine the extent and severity of this problem, we reviewed consecutively reported, anticoagulation-related medication errors over a 3-year period. We identified 130 medication errors. There were 1.67 medication errors for every 1,000 patients treated with anticoagulants. These were most often associated with unfractionated heparin (66.2%), followed by warfarin (21.5%), low-molecular-weight heparin (9.2%), argatroban (1.5%), and lepirudin (1.5%). There were no deaths attributed to any anticoagulant medication errors, but 6.2% of patients required medical intervention and 1.5% needed prolonged hospitalization. Medication errors frequently occur with anticoagulant therapy in hospitalized patients.
Subject(s)
Anticoagulants/therapeutic use , Drug Therapy, Computer-Assisted , Medication Errors/statistics & numerical data , Medication Systems, Hospital/statistics & numerical data , Thromboembolism/drug therapy , Anticoagulants/adverse effects , Boston , Cross-Sectional Studies , Dose-Response Relationship, Drug , Drug Administration Schedule , Heparin/adverse effects , Heparin/therapeutic use , Humans , Patient Care Team/statistics & numerical data , Research Design/statistics & numerical data , Risk Management/statistics & numerical data , SoftwareABSTRACT
UNLABELLED: CREATING A PATIENT SAFETY TEAM: In May 2001 Brigham and Women's Hospital (Boston) created the Patient Safety Team, which was incorporated into the pre-existing safety and quality infrastructure. ESTABLISHING THE PATIENT SAFETY TEAM'S GOALS AND INITIATIVES: The goal was to create the safest possible environment for patients and staff by creating a culture of safety, increasing the capacity to measure and evaluate processes, committing to change unsafe processes, and adopting new technologies. To achieve this mission, the following initiatives were established: create a culture of safety, increase event identification, improve event analysis, close the feedback loop, assess risk proactively, improve medication safety, and involve the patient. DISCUSSION: Integrating the Patient Safety Team into pre-existing committees and departments facilitated its work while helping to reinforce the multidisciplinary nature of safety efforts. It is critical that pre-existing groups feel that patient safety represents value added and is not a threat to their current roles. SUMMARY AND CONCLUSIONS: If a patient safety strategy and team are to be effective, commitment from the organization's leaders is essential. This team should also work with individual departments and pre-existing quality structures to drive changes to the systems of care to enable health care to become as safe as possible.
