Types and causes of anticoagulant-related medication incidents across hospitals in Western Australia

Background: Anticoagulant medications are widely prescribed for the treatment and prevention of thromboembolic disorders. They are considered high-risk medications due to their narrow therapeutic window and potential to cause serious fatal haemorrhagic or thromboembolic complications. Aim: This study analysed all reported medication safety incidents related to anticoagulants across Western Australian (WA) public hospitals over a 12-month period to determine possible causative factors. Methods: A mixed-methods study of all reported anticoagulant-related medication incidents between 1 July 2016 and 30 June 2017 across 93 WA public hospitals was conducted. The study identified the confirmed level of harm that occurred to patients, the phase during the medication management cycle when the incident occurred, the incident type and causative factors. Results: Six per cent (n = 417) of all medication-related clinical incidents reported during the study period involved anticoagulants, of which 0.2% caused significant harm and 6.7% caused moderate harm. Most incidents occurred during the administration phase (69.1%). The most frequent incident type reported was omission of dose (29.5%) and the most frequent causative factors reported were inadequate checking process (20.7%; n = 746) and inadequate documentation (18.8%). Conclusion: Most anticoagulant incidents occurred during the administration phase, with inadequate checking processes and incomplete or illegible documentation being the most frequently reported causative factors. Review of direct oral anticoagulant-reported incidents identified staff knowledge deficits with regard to indication-based dosing and dose modification requirements in renal impairment. These findings contributed towards development of targeted strategies and education resources to reduce the incidence of anticoagulant-related medication incidents.