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Anticoagulation Top Prevention Highlights

National action plan for adverse drug event prevention

  • Safer care: Improve provider knowledge of high-quality inpatient anticoagulation management through education and the dissemination evidence-based, inpatient anticoagulation management strategies and tools.
  • Effective communication and coordination of care: Improve electronic health record tools to provide access to real-time, linked pharmacy-laboratory data and order sets. Integrate anticoagulation-specific order sets and titration protocols into currently existing care transition models. Consider pharmacist-based discharge instructions.

Practice guidelines

Consider the following practice and prevention guidelines:

  • Appropriate baseline laboratory values (hemoglobin and hematocrit, serum creatinine or platelet count) are obtained prior to the initiation of anticoagulant therapy.
  • A baseline assessment of the patient’s medical history and risk factors (e.g., history of trauma, heparin-induced thrombocytopenia, prior anticoagulant use) is performed prior to prescribing anticoagulant therapy. An actual metric weight is obtained for patients on continuous heparin therapy.
  • A baseline international normalized ratio is obtained on all patients admitted on or started on warfarin therapy.
  • Patients on warfarin have an order for daily INR monitoring.
  • Disease-specific standard order sets (deep vein thrombosis, atrial fibrillation, pulmonary embolism) are readily available and used to provide appropriate and safe anticoagulant therapy.
    • Standardized heparin protocols are available and used.
  • Establish protocols for standardized rapid (emergency) reversal of anticoagulation.
  • Standard weight-based protocols and order sets avoid the use of “u” to indicate “units” of heparin.
  • Computerized prescriber order entry and pharmacy information systems alert providers to duplicate anticoagulant therapy and serious drug interactions/contraindications.
  • Heparin flush, when necessary, is available in prefilled syringes.
  • Concentrated heparin vials (e.g., 10,000 units/mL or 20,000 units/mL) are not available in automated dispensing cabinets or unit stock.
  • Continuous heparin infusions are administered using a smart infusion device, which includes dose error reduction software.
  • Independent double check for intravenous heparin therapy occurs prior to administration, at each rate change and with each infusion bag change.
  • Discharge counseling for patients on anticoagulants is provided by a pharmacist.
  • Written materials on the risks of therapy and signs of toxicity are provided at the time of discharge.
  • Laboratory results (aPTT) are available in two hours or less for patients on continuous heparin therapy.

Other key interventions

  • Secure administrative leadership commitment: Dedicating necessary human, financial and technology resources.
  • Establish professional accountability and expertise: Appointing a single leader responsible for program outcomes, supported by at least one clinician with expertise in anticoagulation management.
  • Engage multidisciplinary support: Involving key specialists and disciplines to obtain perspective from all domains of the care delivery system.
  • Ensure high reliability: Collect, track, trend and analyze data to trigger the need for further improvement or validate excellent outcomes.
  • Implement systematic care: Ensure the care is integrated with nursing assessments, treatments and non-pharmacological interventions.