| Primary Author: | Samrah Ahmad, PharmD, BCPS |
| Co-Principal Investigators/Collaborators: | Rehana Jamali, PharmD, Leonard T. Langino, MS, RPh |
| Organization | North Shore University Hospital |
Abstract
Purpose
To measure effectiveness of specific safety strategies implemented to optimize therapeutic benefits and minimize risks associated with anticoagulant therapy
Background
Anticoagulation therapy is an effective measure of preventing and treating thrombosis. Anticoagulants require comprehensive dosing and monitoring strategies to minimize the risks associated with their use and to maximize patient outcomes. The Joint Commission’s (JC) National Patient Safety Goal targets reducing the likelihood of patient harm associated with anticoagulants such as heparin (unfractionated), low-molecular-weight heparin, warfarin, and other anticoagulant drugs.1 U.S. Pharmacopeia lists anticoagulants as high-risk medications and among the top 12 drugs associated with medication errors.2 Standardizing anticoagulation therapy can help reduce bleeding complications and decrease the number of adverse drug events and medication errors. This leads to safer care, a reduction in mortality and possibly shortened length of hospital stay3. Processes need to be implemented and routinely monitored to meet requirements of national accrediting bodies and most importantly to improve patient safety and care.
Materials & Methods
Anticoagulant Therapy Policy for Adults was developed in 2010, encompassing policies and procedures to address prescribing, dispensing and administration of anticoagulants. A process was implemented for the pharmacist to review baseline and current INR values when reviewing orders for warfarin and guidelines were developed to recommend dosage adjustments for supra-therapeutic INRs. A consult service was also developed to provide detailed patient education on anticoagulants by a clinical pharmacist. Through the Anticoagulation Safety Committee anticoagulant related near-misses, medication errors, and suspected drug reactions were extracted from and analyzed. Based on this data, several safety initiatives were implemented including; development of weight based heparin order form and dosing nomograms also continuous monitoring of the form to identify opportunities to improve practice; and implementation of heparin task force to specifically evaluate occurrences associated with heparin misadministration. In 2009 a Thromboprophylaxis Order Form was created to improve rates of Venous Thromboembolism (VTE) prophylaxis based on ACCP guidelines. In 2010 the compliance with the use of the form was monitored monthly and reported to the hospital Performance Improvement Coordinating Group (PICG), Pharmacy and Therapeutics Committee and various departments through out the hospital to improve the use of appropriate prophylaxis. A process was developed to monitor all patients on argatroban therapy by a clinical pharmacist. Appropriateness of therapy was assessed and recommendations were made to optimize bridging to warfarin therapy. Outcome Measures included incidences of supra-therapeutic INRs per warfarin orders dispensed, near misses related to heparin, compliance rate with VTE assessment, and Argatroban number of patients days of therapy per patient.
Results
Over an 8 month period in 2010 there were 23,030 Warfarin orders reviewed, INRs monitored, and recommendations for dose adjustments made by the pharmacists. There was a 25% decrease in critical values reported per warfarin orders after the initiation of pharmacist monitoring of INR. Near misses were monitored and trended on a monthly basis for Heparin. A large number of the near misses were related to the diluent not being selected or due to therapeutic duplication with prophylactic doses of anticoagulants not being discontinued prior to initiating intravenous heparin. The order form was revised to include these as default. Heparin dropped from the top near miss in 2008 and 2009 down to number three during 2010. The VTE assessment compliance was assessed monthly starting in March 2010 with continued feedback and education rates continued to trend up from 77% in March to 89% in December 2010. During the year 2010 number of patients on Argatroban decreased from 125 to 77 as compared to 2009 (38% decrease). Days of therapy per patient decreased from 6.6 to 4.7 (30% decrease).
Conclusion
Anticoagulants are high risk medications, initiatives are needed to improve patient safety and enhance quality of care. The Pharmacy Department has played a vital role in spearheading these initiatives including involvement in warfarin order reviews and INR monitoring, heparin monitoring, thromboprophylaxis compliance monitoring, and argatroban monitoring. Multidisciplinary strategies were implemented to achieve these measures; however, there is a need for continued effort in this area to improve upon patient safety and quality of care.
Bibliography
The Joint Commission. Reducing anticoagulation- related adverse drug events: closely monitoring and managing risks for patients on warfarin. Jt Comm Perspect Patient Saf 2006 Jul;6(7):3-4.
U.S. Pharmacopeia. Top 50 drug products* associated with medication errors [online]. [cited 2008 June 18]. Available from Internet:http://.usp.org/hqi/patientSafety/resources/top50DrugErrors.html.
Pa Patient Saf Advis 2008 Sep;5(3):81-4
© Improvement Science Research Network, 2012
The ISRN published this as received and with permission from the author(s).