Welcome to the second issue of 2017. This edition focuses on one well-known high-risk medication, the oral anticoagulant warfarin. Similar issues appeared in cases we presented almost 10-years ago in the RAC-Communiqué December 2008. The cases included this time highlight the human factors or systemic issues around medication use and their management.
This Clinical Communiqué case study discusses the death of a patient who was at a significantly increased risk of medication harm. Recently discharged from hospital, the patient had been prescribed a new medication and treated with a medication requiring therapeutic monitoring (warfarin), all with the involvement of a number of different healthcare providers. The coroner’s finding highlighted the importance of a framework for safe medication prescribing, and the dispensing, administering and monitoring of medications.