Medication Error Case Study
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TopicsAll TopicsAtrial FibrillationCardiovascular DiseasesCOPDMen's HealthDiabetes Type 2PainHIV AIDSNervous System DiseasesObesityRespiratory Diseases MAIN MENU Home Topics Dermatology Cardiovascular Diabetes GI HIV/AIDS Conferences Quizzes Photoclinic Image IQ Pediatrics Welcome Guest | Login or Register Welcome My Account|My Account or Logout Search form http://www.patientcareonline.com/nervous-system-diseases/medication-errors-adults%E2%80%94case-1-warfarin Search Patient Care OnlineAll Sites Topics:Atrial Fibrillation|Cardiovascular Diseases|COPD|Men's Health|Diabetes Type 2|Pain|HIV AIDS|Nervous System Diseases|Obesity|Respiratory Diseases|Browse All TopicsAll TopicsAtrial FibrillationCardiovascular DiseasesCOPDMen's HealthDiabetes Type 2PainHIV AIDSNervous System DiseasesObesityRespiratory Diseases ubmslateCL-logo-ubm ≡ Main menuHomeTopicsBuyer's GuideJournal MAIN MENU Home Topics Dermatology Cardiovascular Diabetes GI HIV/AIDS Conferences Quizzes Photoclinic Image IQ Pediatrics Medication Errors in Adults—Case #1: Warfarin Medication Errors in Adults—Case #1: Warfarin July 29, medication error 2013 | Nervous System Diseases, Atrial Fibrillation, InfectionBy Bradley M. Wright, PharmD, BCPS Medication errors may occur at any point in the health care system. Obtaining a true estimate of the number of errors is difficult, but preventable medication errors are known to increase patient harm and total health care costs.1 This series will highlight some of the most important errors and medication error case address methods to decrease the risk of them occurring. Drug #1: WarfarinA 52-year-old male taking warfarin daily for prevention of stroke with atrial fibrillation develops a skin infection and visits the local urgent care center on a weekend for evaluation and treatment. The patient receives a diagnosis of cellulitis and a prescription for Bactrim®, trimethoprim/sulfamethoxazole (TMP/SMX), to be taken twice daily. The drug is dispensed by a pharmacy near the urgent care center, not the patient’s usual pharmacy. Several days later, the patient is admitted to the hospital with an acute bleed and an elevated international normalized ratio (INR).What is the problem in this scenario?DiscussionWarfarin remains one of the most frequently prescribed medications in the United States, and it appears on the Institute for Safe Medication Practices list of high-alert medications because overanticoagulation or underanticoagulation has important consequences.2 In addition, medication errors that lead to adverse drug events may be more common with warfarin because it has a large number of drug-drug and drug-food interactions and there is a need for increased INR monitoring.In the scenario above, a medication was prescribed that was kn
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