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.