الفهرس 
Literature ReviewOnly 14 pages are availabe for public view
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Abstract
from the obtained results, it can be concluded that anticoagulants as a class of drugs significantly contribute to medication errors with more than half of them caused by incorrect doses (either low or high dose). Physicians’ adherence to guidelines was strongly associated with the number and severity of medication errors. Moreover, polypharmacy significantly increased the probability of medication errors.
The anticoagulation stewardship program promotes a culture of safety around anticoagulants, reduces the medication errors and their severity, and increases physician adherence to guidelines.
Limitations
The study does not require or use any more funds; it is solely based on clinical pharmacist efforts and the cooperation of the health care team. However, the study was limited by investigators (clinical pharmacist team) working hours as they work 12 hours per day rather than 24 hours per day, so the program was only followed during this time period. In addition, the number of patients on direct oral anticoagulants in the study was limited.
Recommendation
Further research should focus on the same determinants in diverse settings, such as private hospitals, teaching hospitals, and outpatient departments. Future research can highlight the cost-saving effect of stewardship and should expand the program to include antithrombotic agents and prescribing reversal agents in addition to anticoagulants. Furthermore, additional research on larger number of individuals on direct oral anticoagulants regimens might be beneficial.
Summary
Anticoagulant agents have the potential of causing significant harm to patients if not prescribed properly, which qualifies them to be among high-alert medications. The implications of anticoagulant-related medications errors are unquestionably severe to the patients who use them, regardless to how common they are among other medication classes. Anticoagulants belong to the top five medications involved in potentially preventable hospital admissions related to medication. It is estimated that (7.2%) of medication errors are related to them.
Anticoagulants management represents a real challenge in hospitalized patients. This is attributed to the wide variety of pharmacodynamics and pharmacokinetic properties of anticoagulant agents. Furthermore, inpatients suffer from acute and more complex disorders that require switching between parenteral and oral anticoagulant agents and sometimes even interrupting the blood-thinning agent’s regimen while preparing for invasive procedures. All together subject anticoagulant treatment to dietary irregularities and requires a tailored-dosing regimen of anticoagulants. The aim of the study is to implementation of clinical pharmacist-led anticoagulation stewardship program in Egyptian tertiary hospital to promote a culture of safety around anticoagulants and evaluate the impact of the program on anticoagulation therapy outcomes during patient hospitalization period by reduction percentage of medication errors and adverse drug events and physician adherence to evidence-based guidelines improvement
The study was a single center prospective study among hospitalized patients on anticoagulant agents. It is consisted of three phases to implement a clinical pharmacist-led anticoagulation stewardship program (pre-implementation, Implementation, and post, implementation).
A total of 233 patient enrolled in the study pre-implementation phase = 116 patients post-implementation phase =117 patients.
Inpatients on anticoagulation therapy were enrolled in the study and were followed up during their period of hospitalization until discharge. The clinical pharmacy department at the hospital provides services 12 hours a day. Clinical pharmacists were responsible for collection of data in a multidisciplinary and multilayered approach.
The study result showed that the medication errors were reduced by (50%). The proportion of wrong doses/total doses decrease from 0.474 ± 0.044 to 0.432 ± 0.04 (p =0.003). while adverse drug events decreased numerically from (2.6% to 1.7%) (p =0.64). Physician adherence to evidence-based guideline improved as full adherence increased (40.8% to 60.2%) (p =0.001) and non-adherence decreased from (26.7% to 3.4%) (p =0.001).
Conclusion: The anticoagulation stewardship program promotes a culture of safety around anticoagulants, reduces the medication errors and their severity, and improve physician adherence to guidelines.