Contributory factors and patient harm including deaths associated direct acting oral anticoagulants (DOACs) medication incidents: evaluation of real world data reported to the national reporting and learning system.

A total of 15,730 incident reports were analyzed. A total of 25 deaths were reported with a further 270 and 55 incidents leading to moderate and severe harm respectively. A further 8.8% ( = 1381) of incidents were associated with low degree of harm. The majority of the incidents involved active failures ( = 13776; 87.58) including duplication of anticoagulant therapies, patients being discharged without DOACs, non-consideration of renal function and lack of commencement of DOACs post-surgery suggesting preventability of such reported incidents. This study shows that medication incidents involving DOACs hence have the potential to cause severe harm and deaths and there is a need to promote guideline adherence through education, training and decision support technologies.