Background and importance Anticoagulants are used hospital wide throughout the patient trajectory involving many healthcare providers. Given their widespread use and risk profile, they are classified as high risk. Despite the many precautions and vast experience with these drugs, errors often occur in daily practice.
Aim and objectives To investigate which factors currently negatively affect patient safety in our hospital.
Material and methods We performed a retrospective data analysis based on incident reports and registered usage (2018–2019) as well as on pharmaceutical recommendations (3 months period in 2019) related to anticoagulants and antiaggregants. The data were obtained from the hospital information systems. Additionally, we surveyed doctors and trainees working in our hospital, via Google Forms, asking multiple choice questions inquiring into their experiences. They were asked to participate via email, and participation was voluntary and anonymous. All data were processed via Microsoft Excel and discussed within the anticoagulation stewardship committee.
Results Retrospective data analysis: 172 incidents and 132 pharmaceutical recommendations were included. Most incidents were related to low molecular weight heparin (45%) and took place in a surgery ward (37%). In 35% of cases, the incident could be linked to transfer to another ward or operating room. Problems in terms of administration (38%), communication (30%) and prescription (24%) were the main risk factors.
Survey: 74 doctors, representing 21 disciplines, answered the questionnaire. Non-prescribing of therapy was considered to be the main problem (49%), followed by incorrect dosing (42%). Lack of communication was a tricky issue: only 23% agreed that the patient receives sufficient information on paper. 51% thought that the policy was followed consistently hospital wide. Only 28% thought that new employees were sufficiently informed about the hospital wide agreements. Additional monitoring by a clinical pharmacist would be considered an added value by 88% of the doctors.
Conclusion and relevance A number of risk factors were identified, such as education of all healthcare professionals, communication, the IT systems used, the opening of temporary wards and transfer of patients within the hospital. It is our opinion that a multidisciplinary, centralised approach with a focus on monitoring is imperative. The use of a clinical pharmacist could play an important role.
Conflict of interest No conflict of interest
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