Analysis and prevention of medication errors of dabigatran etexilate and rivaroxaban

doi:10.19803/j.1672-8629.20210674

Abstract

Abstract: Objective To discuss the occurrence and influencing factors of medication errors (ME) of dabigatran etexilate and rivaroxaban, and provide evidence for formulating targeted preventive measures. Methods The ME reports of dabigatran axetil and rivaroxaban between January 1, 2016 and December 31, 2020 of the National Clinical Safety Drug Monitoring Network were collected, and the classification, error content, error causing personnel, error finding personnel and causing factors of ME were analyzed. Results A total of 100 ME reports of dabigatran etexilate and rivaroxaban accounted for 0.17% of the total ME reports (59 949 cases), of which 5 were severe ME reports , which accounted for 0.98% of the total severe ME reports (508 cases). After a case-by-case review, 98 cases finally met the requirements, including 65 males and 33 females, with an average age of 62.45 (29~92) years. Grade B errors were the most, 76 cases (77.55%); severe ME reports 4 cases (4.08%), manifested as bleeding and bleeding tendency, and the wrong factors were drug interaction and perioperative anticoagulant use. The top three errors caused by physicians (45 cases, 45.92%) were indications, dosage and quantity/frequency;the top three errors caused by pharmacists (43 cases, 43.88%) were the quantity, specification, and variety. The people who found the errors were mainly pharmacists (77 cases, 78.57%). The top three factors causing errors were lack of knowledge/inadequate training, fatigue, and look-alike /sound-alike medicine. Conclusion The proportion of severe ME of dabigatran etexilate / rivaroxaban is greater than of total ME. It is important to pay attention to the procedure of prescription and dispensing. Equally, it is necessary to strengthen the training of medical staff in rational drug use and adjust the work intensity to reduce and avoid lack of knowledge/fatigue. Clinical decision support system such as pre-review prescriptions and automated drug delivery systems can be introduced to assist in reducing ME according to conditions.

Key words: dabigatran etexilate, rivaroxaban, new oral anticoagulants, medication errors, risk prevention

CLC Number:

R994.1

ZHANG Qingxia, DING Qian, YAN Suying, WANG Yuqin. Analysis and prevention of medication errors of dabigatran etexilate and rivaroxaban[J]. Chinese Journal of Pharmacovigilance, 2022, 19(12): 1372-1375.

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