Errors Related To Blood Thinners All Too Frequent

Patients should be aware of the inherent dangers of blood thinners. The stories are becoming all too frequent in the news. There are numerous reports of accidental overdoses. Greater attention needs to be paid to unsafe practices, negligent errors, and the elusive nature of anticoagulant agents.

Anticoagulant medication errors are such a serious patient safety issue that the Joint Commission addressed these types of errors in the 2008 National Patient Safety Goals. Stricter guidelines need to be met immediately.

Factors that contribute to anticoagulant medication errors include: lack of standardized labeling and packaging, failure to document and communicate patient instructions during hand-offs, and inappropriate dosing for pediatric patients.

Recently, a woman had hip replacement surgery performed on her. The surgery was a success and she was doing fine while in recovery. Suddenly, she started bleeding out of the mouth and nose. Her blood pressure skyrocketed. She instantly presumed that she was near death.”I am dying”, were her exact words. I personally know this woman. Fortunately, she is doing much better now.

After a trip to the emergency room, it was discovered that she had been given twice the dosage (of blood thinner medication) than normally what should have been prescribed.

In this case, there was a failure of communication during hand-offs between two doctors. The numbers were misread. How could this happen in the age of information? What action can be taken to prevent this from happening again in the future?

Although the patient recovered, she could have died because of a major medical error. Other patients have not been so fortunate.

In July of 2008, 14 babies were overdosed at the Christus Spohn Hospital, in Corpus Christi, Texas. Blood thinner medications were given in the wrong dosage repeatedly to infants. This accident was due to an error at the hospital pharmacy, and not the results from labeling.

Hospitals made nearly 60,000 errors involving blood thinners over a five-year period, according to an article in the Personal Liberty Digest. There were 28 patient deaths between January 1997 and December 2007.

“The systems necessary to ensure that these drugs are used safely are not adequate,” commented Dr. Mark R. Chassin, president of the Joint Commission.