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Prevent Harm from High Alert MedicationAnticoagulants in Primary Care
Presenter:
Preventing Surgical Complications
Introduction
• The 1000 lives campaign focuses on the
implementation of proven interventions to save
lives and reduce harm to patients in NHS
Wales
• The aim of this intervention is to reduce the
likelihood of patient harm associated with the
use of anticoagulation therapy in primary care
Preventing harm from High Alert Medication- Anticoagulants
Rationale
• In Wales there are more than 20,000 patients
taking oral anticoagulants in primary care
• 1° care - Anticoagulants are one of the
classes of medicines most commonly
associated with fatal medication errors.
• 2° care- Warfarin is one of the ten drugs most
frequently associated with dispensing errors.
Preventing harm from High Alert Medication- Anticoagulants
Rationale
• The NHS Litigation Authority has reported that
medication errors involving anticoagulants fall
within the top ten causes of claims against NHS
trusts
• Anticoagulants are one of the classes of
medicines most frequently identified as causing
preventable harm and admission to hospital
(Pirmohamed M et al. 2004, Howard RL et al.
2007)
Preventing harm from High Alert Medication- Anticoagulants
NPSA Risk Assessment
• NPSA risk assessment 2006 found:
–120 deaths
–480 serious harms
–anticoagulants the second therapeutic
group (after opiates) causing the most
deaths and severe harm
Preventing harm from High Alert Medication- Anticoagulants
Why such a problem?
Adverse drug events are common with Warfarin
due to• Complexity of dosing and monitoring
• Patient compliance
• Biological variation in response to treatment
• Numerous drug interactions
• Dietary interactions that can affect drug levels
Preventing harm from High Alert Medication- Anticoagulants
NPSA Recommendations
• Following the NPSA Risk Assessment
2006 a series of safer practice
recommendations were issued, along
with Alert 18 and an NPSA anticoagulant
audit for all primary and secondary care
providers to use
Preventing harm from High Alert Medication- Anticoagulants
The Safer Practice
Recommendations
• Training and work competencies required
• The need to update procedures and
protocols
• The need for audit of anticoagulant
services safety indicators
• The need for improved information and
counselling for patients
Preventing harm from High Alert Medication- Anticoagulants
Where are we now?
• Anticoagulant management has been
adopted as part of the SPI 2 initiative
taking place in participating Welsh
hospitals
• The NPSA Patient Safety Alert 18 is
being implemented at present throughout
primary and secondary care in Wales.
Preventing harm from High Alert Medication- Anticoagulants
Campaign Aim
• Draw current processes together
• Measure implementation of process
changes
• Evaluate what has achieved an impact
• Support clinical teams in spreading those
elements in a managed way
Preventing harm from High Alert Medication- Anticoagulants
How?
• Standardise and simplify core medication
processes in known high-risk areas,
• redesign delivery systems using proven
human factors principles
• partnering with patients
• create safety cultures that minimise
blame and maximise communication
Preventing harm from High Alert Medication- Anticoagulants
General principles
• Design processes to prevent errors and
harm.
• Design methods to identify errors and
harm when they occur.
• Design methods to mitigate the harm that
may result from the error.
Preventing harm from High Alert Medication- Anticoagulants
Measurement Strategies
Successful measurement is a cornerstone of
successful improvement.
• Use sampling to make measurement efficient.
• Integrate measurement into people’s daily
routine.
• Plot data on the measures over time, and post
results so that teams can see their progress.
Preventing harm from High Alert Medication- Anticoagulants
Process Measures
• % Patients Receiving Anticoagulant with
Treatment Appropriately Managed
According to Protocol
• % of Patients Receiving Anticoagulant
without appropriate written clinical
information e.g. indication, target INR,
stop date
Preventing harm from High Alert Medication- Anticoagulants
Evidence
• Failure to implement professional
guidelines concerning the prescribing,
counselling, monitoring and administering
of anticoagulants is an important
underlying cause of harm (NPSA 2006)
Preventing harm from High Alert Medication- Anticoagulants
Outcome Measures
• Adverse Drug Events Related to
Anticoagulant in previous month with
Anticoagulant Administered
• % of Patients Receiving Warfarin with
INR Outside Protocol Limits
Preventing harm from High Alert Medication- Anticoagulants
Outcome Measures
• % of Patients Receiving Warfarin with
INR >5 but <8
• % of Patients Receiving Warfarin with
INR >8
• % of Patients Receiving Warfarin with no
INR recorded
Preventing harm from High Alert Medication- Anticoagulants
Evidence
• It is accepted as a good standard of care
if patients are within the target range of
INR 60% of the time (Machin, 2002).
• Risk of haemorrhage whilst on long term
anticoagulation varies between 1 and
15% per annum and the risk of death
increases with increasing INR (Oden and
Fahlen 2002).
Preventing harm from High Alert Medication- Anticoagulants
Measures
• These measures do not measure harm
directly, serve as more-easily-collected
proxies for negative clinical outcomes
associated with high-alert medications.
• Measures can and should be used as
starting points in case-by-case
investigations of how the care system
may have failed.
Preventing harm from High Alert Medication- Anticoagulants
Audit+ tool
• data can be plotted monthly to monitor how the
service is improving and where patterns indicate an
area for further change.
– Number of patients on anticoagulants
– % INR in range
– % INR over 5
– % INR over 8
– % with no INR recorded
– % recorded with ADR in last month
Preventing harm from High Alert Medication- Anticoagulants
Summary
• NPSA alert underway, but we can still
work to improve safety with
anticoagulants.
• Consider key areas after implementation
– review success of implementation –
consider using PDSA to prove or improve
safety of Warfarin.
Preventing harm from High Alert Medication- Anticoagulants
PDSA
• Small changes, one patient, one list, one team
• Spread if did work
• Measure – did it work, if not try something
different
• Identify a pilot population
• Measure
• Are you already doing it? – measure
compliance
Preventing harm from High Alert Medication- Anticoagulants
Day 2
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Review the interventions made
Decide which you are taking forward
Local action plan
Identify first test of change
What are the challenges
Preventing harm from High Alert Medication- Anticoagulants