Date
of Last Review: 1/14/09
SME: Director of Pharmacy
POLICY:
| Based on the evidence presented in the medical literature and recommendations from organizations that support safe medication use and Joint Commission on Accreditation, these elements have been selected for implementation across UTHCPC in order to facilitate the development and implementation of practices that optimize therapeutic benefits and minimize risks associated with anticoagulants |
PURPOSE:
| To ensure the safe use of anticoagulation therapy in the hospital. |
PROCEDURES:
General
A. |
The organization reviews medication errors related to anticoagulants on an ongoing basis and identifies and implements improvement strategies as part of the organization-wide adverse drug event program. |
B. |
At least annually, prescribers, nurses, and pharmacists receive education on the safe use of anticoagulants. |
C. |
Baseline laboratory tests (e.g., hemoglobin, hematocrit, serum creatinine, platelet count, INR, aPTT) are obtained before anticoagulants are ordered, and procedures are in place to ensure that for patients receiving anticoagulant therapy laboratory study results are available and used to monitor and adjust therapy |
D. |
Pharmacy participates in the development and implementation of protocols, guidelines, or procedures for dosing and monitoring anticoagulation therapies. |
E. |
Pharmacy participates in a facility-wide effort to evaluate the safety of anticoagulant use. |
F. |
Pharmacy works in collaboration with Dietary services and submit on a daily basis a list of all the patients on anticoagulation therapy for drug food interaction review. |
G. |
Pharmacy participates in a facility-wide effort to evaluate the need for and provide patient/family education. |
Dispensing
A. |
Warfarin |
1. |
Pharmacists screen warfarin orders for possible drug interactions. |
2. |
Upon request, pharmacists provide patient education on warfarin, including written information that addresses possible food-drug interactions. |
3. |
Pharmacists monitor a patient’s INR prior to dispensing a dose. |
4. |
Exact patient doses are dispensed. |
5. |
Pharmacy dispenses single use or unit-dose packages to patient care units. |
Administration
A. |
Warfarin |
1. |
A standard administration time is established based on patient medication history and intake from the admitting nurse including the patient’s medication from home. |
Protocols
A. |
Protocols for standard and rapid reversal are established for warfarin (see protocol). |
Process Improvements
A. |
The organization reviews medication errors related to anticoagulants on an ongoing basis and report to the Pharmacy and Therapeutics Committee and identifies and implements improvement strategies as part of the organization-wide adverse drug event program |
| ACCP Guidelines for the Management of Excessive Anticoagulation With or Without Bleeding |
|---|
| INR | Symptom | Action |
|---|---|---|
| INR above therapeutic range but < 5 | no significant bleeding | Lower dose or omit dose, monitor more frequently, and resume at lower dose when INR is therapeutic; if only minimally above therapeutic range, no dose reduction may be required. |
| INR ≥ 5 but < 9 | no significant bleeding | Omit the next one or two doses, monitoring INR more frequently, and resume therapy at lower dose when the INR is therapeutic level. Omit a dose and administer vitamin K (1 to 2.5 mg) orally, particularly if the patient is at increased risk of bleeding. If more rapid reversal is required due to surgery, we suggest vitamin K (≤ 5 mg) orally, with the expectation that a reduction of the INR will occur in 24 hours. If the INR is still high administer additional vitamin K (1 to 2 mg) orally. |
| INR ≥ 9 | no significant bleeding | Hold warfarin therapy and administer vitamin K (2.5 to 5 mg) orally, with the expectation that the INR will be reduced substantially in 24 to 48 hours. Monitor the INR more frequently and administer additional vitamin K if necessary. Resume warfarin therapy at a lower dose when the INR is therapeutic. |
| Any INR Elevation | Serious/Life threatening bleeding | Hold warfarin therapy and TRANSFER PATIENT TO BENTAUB IMMEDIATELY. |
Related Standards
| The Joint Commission : National Patient Safety Goals | |
| Institute for Safe Medication Practices. ISMP Recommended Safety Improvements for Anticoagulants. ISMP Medication Safety Alert 2007; 12(1) |
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