Contributions
Abstract: PB2386
Type: Publication Only
Background
Anticoagulant prescribing, dispensing and administration continue to be a source of preventable near misses and harmful events in healthcare settings. Patients often have complex comorbidities and polypharmacy; which can mean they are more vulnerable to potential over- or under- anticoagulation and the resulting adverse effects.
Breakdowns in communication between staff or confusion about warfarin prescribing, monitoring and administration have been cited as a major factor in adverse events.
Aims
The National Patient Safety Agency (NPSA) issued guidance aimed at preventing harm as a result of anticoagulant use in 2007 - this project assesses how well this hospital adheres to this guidance ten years on from its release.
Methods
A literature review was performed and audit standards were agreed with the multi-disciplinary team. Data was collected from electronic patient and prescribing records as well as patient notes, during April-May 2017.
Approval was granted by the local governance department.
Results
- 84% of patients on warfarin had a documented indication and target INR range
- 39% of patients had significantly deranged INR; appropriate action was taken in 67% of cases
- Prescription times varied greatly; 49% were prescribed on time (before 2pm), 17% were prescribed after 5pm
- Administration times varied; 47% were administered before 4pm, 4.5% administered after 8pm
Conclusion
There are still improvements to be made. The variation in standards are undoubtedly multifactorial; late return of INR results, heavy workload of ward teams, failure to handover to on-call teams, and the use of agency nursing staff (without e-prescription access) are some of the contributory factors postulated at this hospital.
A plan is in place to change practice and improve compliance with NPSA. The audit highlighted the requirement to maintain training for all medical staff, especially as the introduction of direct oral anticoagulants means junior staff are perhaps less familiar with warfarin use nowadays.
Session topic: 36. Quality of life, palliative care, ethics and health economics
Keyword(s): Anticoagulation, Safety, Warfarin
Abstract: PB2386
Type: Publication Only
Background
Anticoagulant prescribing, dispensing and administration continue to be a source of preventable near misses and harmful events in healthcare settings. Patients often have complex comorbidities and polypharmacy; which can mean they are more vulnerable to potential over- or under- anticoagulation and the resulting adverse effects.
Breakdowns in communication between staff or confusion about warfarin prescribing, monitoring and administration have been cited as a major factor in adverse events.
Aims
The National Patient Safety Agency (NPSA) issued guidance aimed at preventing harm as a result of anticoagulant use in 2007 - this project assesses how well this hospital adheres to this guidance ten years on from its release.
Methods
A literature review was performed and audit standards were agreed with the multi-disciplinary team. Data was collected from electronic patient and prescribing records as well as patient notes, during April-May 2017.
Approval was granted by the local governance department.
Results
- 84% of patients on warfarin had a documented indication and target INR range
- 39% of patients had significantly deranged INR; appropriate action was taken in 67% of cases
- Prescription times varied greatly; 49% were prescribed on time (before 2pm), 17% were prescribed after 5pm
- Administration times varied; 47% were administered before 4pm, 4.5% administered after 8pm
Conclusion
There are still improvements to be made. The variation in standards are undoubtedly multifactorial; late return of INR results, heavy workload of ward teams, failure to handover to on-call teams, and the use of agency nursing staff (without e-prescription access) are some of the contributory factors postulated at this hospital.
A plan is in place to change practice and improve compliance with NPSA. The audit highlighted the requirement to maintain training for all medical staff, especially as the introduction of direct oral anticoagulants means junior staff are perhaps less familiar with warfarin use nowadays.
Session topic: 36. Quality of life, palliative care, ethics and health economics
Keyword(s): Anticoagulation, Safety, Warfarin