Reducing Medication Errors – Anticoagulation Medication Safety

Warfarin is at or near the top of recent surveys of medications that lead to ED visits and resulting hospital admissions. Anticoagulation therapy poses risks to patients and too often leads to adverse drug events due to complex dosing, requisite follow-up monitoring, and inconsistent patient compliance. As a consequence, many patients who meet current evidence-based guidelines for warfarin therapy are not being treated at the present time. The use of standardized practices for therapy that include patient involvement can reduce the risk of adverse drug events associated with the use of anticoagulant medications. On January 1, 2009, the Joint Commission goal 3E to reduce the likelihood of patient harm associated with anticoagulation therapy went into effect.

The information available from our November 4, 2008 programs will help clinicians and administrators of anticoagulation services obtain the latest best practices and tools available for safely managing patients on warfarin.

Safely Managing Patients on Warfarin

The information available from our November 4, 2008 programs will help clinicians and administrators of anticoagulation services obtain the best practices and tools available for safely managing patients on warfarin.

Anticoagulation Management In The Ambulatory Setting: Recommendations from the Massachusetts Coalition for the Prevention of Medical Errors

National Patient Safety Foundation Presentation - May 15, 2008,

Physician Survey of Anticoagulation Management Barriers and Improvements Needed

Massachusetts Medical Society 2007 Survey, Elaine Kirshenbaum, MPH

Survey Summary of Findings, Joseph Dorsey, MD

Presentations

Cases and Questions from Strategies for Safely Managing Patients on Warfarin Program - November 4, 2008

Optimizing the Management of Warfarin Therapy, Jack Ansell, MD

Patients with AF: Who Should Be On Warfarin?, Daniel Singer, MD

Vulnerable Time During Patient Transitions, Terrence OMalley, MD

Anticoagulation Transitions: Perioperative Care, Alan Brush, MD

Massachusetts General Hospital Anticoagulation Management Service Clinic Background
and Communications, Lynn Oertel, MS

Staffing, Budgets, and Reimbursement at MGH, Lynn Oertel, MS

Improving Patient Care Management, UMASS Memorial Health Care, Pam Burgwinkle, ACNP-BC

Staffing, Budgets, and Reimbursement at UMASS Memorial Health Care, Pam Burgwinkle, ACNP-BC

Hospital-Based Anticoagulation Clinic at Lahey Hospital Clinic, Ann Pianka, MSN

Anticoagulation Management Service at Brigham & Womens Hospital, Cheryl Silva, Pharm D

Coverage Policies

Coverage Policies Chart

Patient and Family Resources

Patient and Family Resources

Clinical Guidelines and Protocols

Harvard Vanguard Medical Associates: Clinical Guidelines and Practice Protocols – Revised 01/04/12, Alan Brush, MD

Anticoagulation Forum Guidelines

Antithrombotic Therapy in Atrial Fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, CHEST 2008, Daniel Singer, MD

United Kingdom Anticoagulation Guidelines

Tools and Sample Forms

Joint Commission Sentinel Event Alert

AHRQ Resource Materials

Sample Patient Risk Assessment

Clinical Transitions Definitions and Rationales - MGH

Anticoagulation Management Service Brochure MGH AMS

E-Z Guide for Optimizing Warfarin MGH AMS

Sample Patient and Physician Letters MGH AMS

General Resources

Surgeon General's Call to Action to Prevent Deep Vein Thrombosis and Pulmonary Embolism

Patient Informational Website – MyBloodThinner.org – a site to help patients, caregivers, and health care providers manage oral anticoagulants, or blood thinners, more safely.

Process Improvement in the Hospital Setting: Lessons for Successful Implementation of VTE Prophylaxis from the Rochester Regional Thromboembolism Collaborative , June 2008 – To download the Audio Conference, please click here.

Prevention and Treatment of Venous Thromboembolism & Development of National Performance Measures, June 2008 – To download the Audio Conference, please click here.

Anticoagulation Forum Consensus Statement, Jack Ansell, MD

Outpatient Management of Oral Vitamin K Antagonist Therapy: Defining and Measuring High-Quality Management, Cardiovascular Therapy, 2008, Jack Ansell, MD

Quality of Clinical Documentation and Anticoagulation Control in Patients with Chronic NonValvular Atrial Fibrillation in Routine Medical Care, American Journal of Medical Quality, 2007, Jack Ansell, MD

North American Thrombosis Forum (NATF) – is a multi-disciplinary organization founded with the objective of improving patient care through the advancement of thrombosis education.

Key References

Key References