The Healthcare Safety Investigation Branch has launched an investigation into an incident where a hospital inpatient was administered repeated doses of warfarin in error and suffered significant harm as a result. The error was detected after six days by a ward pharmacist.

The investigation will focus on:

  • The systems and processes which underpin the identification, prescribing, and administration of warfarin for frail, older inpatients.
  • The main patient safety risks arising from the prescribing and administration of warfarin and other high risk drugs.
  • The main patient safety defences that act to protect people from medication errors with high risk medicines.

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