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The End of the Yellow Book?
EACS Case Study

Time To Update The Yellow Book?

In primary care, anticoagulants are one of the classes of medicines most commonly associated with fatal medication errors.

In 2002 a Coroner and the Chief Medical Officer highlighted the death of a patient from a Warfarin overdose caused by misinterpretation of a doctor’s handwriting.

In secondary care Warfarin is one of the ten drugs most frequently associated with dispensing errors. The NHS Litigation Authority has reported that anticoagulants are one of the ten most common errors resulting in claims against NHS Trusts.

Anticoagulants were included in the Department of Health Report; Making Medication Practice Safer (2004) as high risk medicines that require the implementation of additional safety controls.

The National Patient Safety Agency (NPSA) contacted the medical and pharmacy defence organisations as well as the NHS Litigation Authority. There have been 480 reported cases of harm or near harm from the use of anticoagulants in the UK from 1990 – 2002.

In addition there have been 120 deaths reported over the same time period. Deaths from the use of Warfarin are responsible for 77% (92 reports) and heparin are responsible for 23% (28 reports).

The NPSA communicated with patient groups, patients and carers to obtain their views concerning their use of anticoagulants. A comprehensive literature review was completed and a risk assessment exercise was undertaken with a multi-disciplinary group on the use of anticoagulants in the NHS.

Using all these methods high risks were identified that contributed to the high incidence of patient harm with anticoagulants. One of the high risks identified was that the yellow book, patient held information, was in need of revision and translation into other languages.

Article reproduced by kind permission of Anticoagulation Europe November 2005 INReview.