Root cause analysis of adverse events in an outpatient anticoagulation management consortium.

Graves CM, Haymart B, Kline-Rogers E, et al. Jt Comm J Qual Patient Saf. 2017;43:299-307.

Anticoagulation confers a high risk of adverse drug events. Examining root cause analyses of anticoagulation–related adverse events, this study found that the majority were not preventable and were due to patient-specific issues. Unlike a prior study, researchers did not include patient perspectives in their analysis, which may have affected their conclusions.

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