- Piazza G, Nguyen TN, Cios D, et al. Anticoagulation-associated adverse drug events. Am j med. 2011;124(12):1136–1142. doi: 10.1016/j.amjmed.2011.06.009
- Institute for Safe Medication Practices. High-alert medications in acute care settings. 2014. cited 20Mar 2023. https://www.ismp.org/recommendations/high-alert-medications-acute-list.
- Mulac A, Taxis K, Hagesaether E, et al. Severe and fatal medication errors in hospitals: findings from the norwegian incident reporting system. Eur J Hosp Pharm. 2021;28(Suppl 2):e56–e61. doi: 10.1136/ejhpharm-2020-002298
- Barr D, Epps QJ. Direct oral anticoagulants: a review of common medication errors. J Thromb Thrombolysis. 2019;47(1):146–154. doi: 10.1007/s11239-018-1752-9
- Afzal S, Zaidi STR, Merchant HA, et al. Prescribing trends of oral anticoagulants in England over the last decade: a focus on new and old drugs and adverse events reporting. J Thromb Thrombolysis. 2021;52(2):646–653. doi: 10.1007/s11239-021-02416-4
- Al Rowily A, Jalal Z, Price MJ, et al. Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis. Eur J Clin Pharmacol. 2022;78(4):623–645. doi: 10.1007/s00228-021-03212-y
- Institute of Medicine (US). Committee on Quality of Health Care in America. To Err is Human: building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, eds. (WA) (DC): National Academies Press (US); 2000.
- Elliott RA, Camacho E, Jankovic D, et al. Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Qual Saf. 2021;30(2):96–105. DOI: 10.1136/bmjqs-2019-010206
- World Health Organisation. Global Patient safety challenge: medication without harm. 2017. Accessed 20 Mar 2023. http://www.who.int/patientsafety/medication-safety/medication-without-harm-brochure/en/.
- McDowell SE, Ferner HS, Ferner RE. The pathophysiology of medication errors: how and where they arise. Br J Clin Pharmacol. 2009;67(6):605–613. doi: 10.1111/j.1365-2125.2009.03416.x
- Department of Health. Building a safer NHS for patients. London: Department of Health, 2001. Accessed 20 Mar 2023. Available from: http://www.dh.gov.uk/assetRoot/04/05/80/94/04058094.pdf
- National Reporting and Learning System. Organisation patient safety incident reports. 2019. Accessed 20 Mar 2023. Available from: http://www.nrls.npsa.nhs.uk/patient-safetydata/organisation-patient-safety-incident-reports/
- NHS Improvement. Guidance notes on national reporting and learning system official statistics publications. 2017. Accessed 20 Mar 2023. Available from: https://improvement.nhs.uk/documents/1728/Guidance_notes_on_NRLS_officia_statistics_Sept_2017.pdf
- Reason J. A systems approach to organizational error. Ergonomics. 1995;38(8):1708–1721. doi: 10.1080/00140139508925221
- Haque H, Alrowily A, Jalal Z, et al. Direct oral anticoagulant-related medication incidents and pharmacists’ interventions in hospital in-patients: evaluation using reason’s accident causation theory. Int J Clin Pharm. 2021;43(6):1693–1704. doi: 10.1007/s11096-021-01302-6
- Linden-Lahti C, Takala A, Holmström AR, et al. What severe medication errors reported to health care supervisory authority tell about medication safety? J Patient Saf. 2021 1;17(8):e1179–e1185. doi: 10.1097/PTS.0000000000000914
- Härkänen M, Vehviläinen-Julkunen K, Murrells T, et al. Medication administration errors and mortality: incidents reported in England and Wales between 2007_2016. Res Social Adm Pharm. 2019;15(7):858–863. doi: 10.1016/j.sapharm.2018.11.010
- Sheikh D, Mateti UV, Kabekkodu S, et al. Assessment of medication errors and adherence to WHO prescription writing guidelines in a tertiary care hospital. Future J Pharm Sci. 2017;3(1):60–64. doi: 10.1016/j.fjps.2017.03.001
- Lopez-Gonzalez E, Herdeiro MT, Figueiras A. Determinants of under-reporting of adverse drug reactions: a systematic review. Drug Saf. 2009;32(1):19–31. doi: 10.2165/00002018-200932010-00002
- Paudyal V, Al-Hamid A, Bowen M, et al. Interventions to improve spontaneous adverse drug reaction reporting by healthcare professionals and patients: systematic review and meta-analysis. Expert Opin Drug Saf. 2020;19(9):1173–1191. doi: 10.1080/14740338.2020.1807003
- GOV.UK. Prescribing medicines in renal impairment: using the appropriate estimate of renal function to avoid the risk of adverse drug reactions. 2019. Accessed 20 Mar 2023. https://www.gov.uk/drug-safety-update/prescribing-medicines-in-renal-impairment-using-the-appropriate-estimate-of-renal-function-to-avoid-the-risk-of-adverse-drug-reactions
- Naseralallah LM, Hussain TA, Jaam M, et al. Impact of pharmacist interventions on medication errors in hospitalized pediatric patients: a systematic review and meta-analysis. Int J Clin Pharm. 2020;42(4):979–994. doi: 10.1007/s11096-020-01034-z
- Avery AJ, Rodgers S, Cantrill JA, et al. A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet. 2012;379(9823):1310–1319. 7. doi: 10.1016/S0140-6736(11)61817-5
- Burnett AE, Barnes GD. A call to action for anticoagulation stewardship. Res Pract Thromb Haemost. 2022 17;6(5):e12757. doi: 10.1002/rth2.12757
- Paudyal V, Hansford D, Cunningham S, et al. Over-the-counter prescribing and pharmacists’ adoption of new medicines: diffusion of innovations. Res Soc Admin Pharm. 2013 1;9(3):251–262. doi: 10.1016/j.sapharm.2012.05.001
- Paudyal V, Hansford D, Cunningham S, et al. Pharmacists’ perceived integration into practice of over-the-counter simvastatin five years post reclassification. Int J Clin Pharm. 2012;34(5):733–738. doi: 10.1007/s11096-012-9668-5
- The Joint Commission. Sentinel event alert: managing the risks of direct oral anticoagulants. 2019. cited 20 Mar 2023. https://www.jointcommission.org/resources/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-61-managing-the-risks-of-direct-oral-anticoagulants
Expert Opinion on Drug Safety
Volume 22, 2023 - Issue 11
Open access
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Original Research
Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the National Reporting and Learning System
Abdulrhman Al RowilySchool of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UKView further author information
, Zahraa JalalSchool of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UKView further author information
& Vibhu PaudyalSchool of Pharmacy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UKCorrespondence[email protected]
https://orcid.org/0000-0002-4173-6490View further author information
Pages 1113-1125
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Received 27 Nov 2022, Accepted 27 Mar 2023, Published online: 18 Jun 2023
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