Table 1:

Examples of Error Prevention Potential Categories.

Examples of SEPCD	Definition	Error prevention potential
Several fills for amlodipine (an antihypertensive medication) only	Unrelated to error	None
One fill for warfarin 6 months ago	Probably would not have prevented error	Low
Several fills for warfarin	Might have prevented error (because knowing about these fills might have resulted in discussion about anticoagulation)	Medium
Several recent fills for dabigatran	Probably would have prevented error	High

Background:

A patient with atrial fibrillation was admitted to the hospital. The initial clinical Admission Medication History (AMH) included no anticoagulant medications.

Subsequent gold standard AMH revealed that the patient had recently switched anticoagulant medications from warfarin sodium 3 mg by mouth daily to dabigatran etexilate 150 mg by mouth twice daily.

Various possible SEPCD results are shown with their error prevention potential.