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Pharmacist-to-Dose DOAC Protocol Reduces Medication Errors
Quick Takes
- Incorporating pharmacist-to-dose protocols for inpatient management of DOACs is associated with a reduction in medication errors.
- Comprehensive, competency-based training and ongoing education are essential when implementing a pharmacist-driven DOAC dosing/monitoring protocol.
- DOAC underdose is a frequently encountered medication error and should be an area of focus for educational efforts for providers and pharmacists.
Study Questions:
Does an inpatient pharmacist-to-dose direct oral anticoagulant (DOAC) protocol impact the number of errors at an academic medical center?
Methods:
This was a retrospective single-center cohort study using a pre-post design to evaluate the impact of a pharmacist-to-dose DOAC protocol on rates of medication errors at an academic medical center. Admitted adult patients who received ≥1 dose of apixaban, rivaroxaban, or dabigatran for an indication of treatment/prevention of venous thromboembolism (VTE) or stroke prophylaxis for atrial fibrillation (AF) during the pre-phase (July 1–December 31, 2019; n = 256) or post-phase (January 1–June 30, 2020; n = 246) were included. The pharmacist-to-dose protocol allowed pharmacists to independently adjust DOAC doses and order labs relevant for dosing; providers were able to opt out of the pharmacist-driven protocol if requested. The primary outcome was difference in patients administered at least one DOAC-related medication error (defined as an error in dosing for indication or renal function, incorrect timing of administration, improper anticoagulant switching, presence of a major drug-drug interaction, or duplication in therapy) pre- or post-implementation of the pharmacist-to-dose DOAC protocol. Secondary outcomes included the components of the primary outcome, rate of near misses (i.e., orders intervened upon by a pharmacist prior to administration), and medication errors at discharge.
Results:
Apixaban was the most commonly utilized DOAC (61.2%), followed by rivaroxaban (32.7%), and then dabigatran (6.2%), with the most common indication being AF stroke prophylaxis (45.4%), followed by acute VTE (29.1%), chronic VTE (22.7%), combined AF and VTE (2.6%), and postoperative prophylaxis (0.2%). A pharmacist-to-dose consult order was placed for 79.7% of patients included in the post-phase.
Fewer medication errors were administered in the post-phase compared to the pre-phase (16% vs. 8.9%; p = 0.017; relative risk reduction 44%). A consistent reduction in administered medication errors was found in the post-phase even when excluding provider managed DOAC orders (16% vs. 7.1%; p = 0.004). The most frequent medication error overall was DOAC underdose, which was similar in both groups (6.6% vs. 6.7% in pre- and post-phase, respectively). The post-phase had a lower incidence of administered medication errors in incorrect timing (3.1% vs. 0.8%), overdose (2.3% vs. 0.8%), incorrect switching (2.3% vs. 0.8%), and major drug-drug interaction (1.2% vs. 0.4%). The post-phase had a numerically higher rate of near misses (7.4% vs. 11.8%; p = 0.1) and fewer discharge medication errors (8.5% vs. 4.9%; p = 0.1).
Conclusions:
This study found that implementation of a pharmacist-driven DOAC protocol was associated with a 44% relative risk reduction in DOAC-related administered medication errors. This finding was primarily driven by reductions in incorrect timing, overdose, incorrect switching, and major drug-drug interactions.
Perspective:
This article described the implementation of a pharmacist-to-dose DOAC protocol at an academic medical center, which was successful in decreasing administered medication errors. Development of the protocol included standardized dosing tables, treatment algorithms, competency-based training, information/resources on less commonly encountered clinical scenarios, and ongoing education initiatives. This article also highlighted that appropriately dosing DOACs is an important target for educational efforts, given DOAC underdose was the most frequently administered DOAC medication error in both provider-managed and primarily pharmacist-managed patients. Future studies should examine the impact of pharmacist-driven DOAC protocols on discharge medication errors and clinical outcomes.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Anticoagulation Management and Atrial Fibrillation, Anticoagulation Management and Venothromboembolism, Atrial Fibrillation/Supraventricular Arrhythmias, Novel Agents
Keywords: Anticoagulants, Atrial Fibrillation, Dabigatran, Drug Interactions, Inpatients, Medication Errors, Near Miss, Healthcare, Patient Care Team, Patient Discharge, Primary Prevention, Pharmaceutical Preparations, Pharmacists, Risk, Rivaroxaban, Stroke, Venous Thromboembolism
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