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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.

We’re providing resources below to assist you in your work to improve anticoagulation management. We’re especially appreciative of the Harvard Vanguard clinicians and staff for taking the time to update their protocols and guidelines every time CHEST makes an update. This document is updated as we receive the latest information from Harvard Vanguard Medical Associates (Alan Brush, MD, FACP, Chief, Cheryl Warner, MD, Senior Physician Consultant, et al).

A message from Alan Brush, MD, MD, FACP, Chief, Anticoagulation Management Service, Harvard Vanguard Medical Associates:

Below is a link to the newly revised AMS Guidelines, now compatible with CHEST-2012 recommendations. In a few situations, our guidelines diverge from the suggestions in CHEST-2012, which are generally based on a weaker level of evidence than the recommendations; where present, we have noted the rationales for this divergence. As examples:

  1. We continue to favor warfarin over the newer oral anticoagulants for most patients; CHEST-2012 suggests use of dabigatran for nonvalvular atrial fibrillation. We have found that cost issues and some post-marketing experience since the publication of CHEST-2012 makes the use of these agents less acceptable to patients. Despite the introduction of Pradaxa nearly two years ago, the number of patients receiving care by AMS has continued to increase.
  2. We now permit loading doses of warfarin for ambulatory patients, but due to certain risks that may have been underestimated in the existing studies, still favor starting with expected maintenance doses for most patients, particularly elderly or frail patients, and those with significant comorbid conditions. CHEST-2012 suggests using 10 mg daily for the first two days on ambulatory patients.
  3. We will be extending the interval of testing to 8 weeks for some stable patients, but not to the extent of “up to 12 weeks” suggested in CHEST-2012.
  4. We will continue to do a bleeding risk assessment on all patients with elevated INRs and make decisions on use of vitamin K on that basis, rather than either routinely use vitamin K for significant INR elevations (common practice in some settings), or not using them routinely unless INR values are above 11.0, suggested in CHEST-2012. Our ability to respond promptly to these situations provides a level of safety not available in many settings, and we believe that vitamin K treatment may be appropriate in patients having other bleeding risk factors with elevated INR values below 11.0.

This major revision, the first since 2008, includes a large number of changes – our service has already been adapting to these recommendations since early this year. We now expect to operationalize the changes. Some very significant updates include:

  • Acceptance of initial loading doses for treatment of acute VTE in uncomplicated patients
  • More cautious approach to changing doses when stable patients have isolated values mildly out of therapeutic range
  • Potential extension of intervals of testing for stable patients beyond the previous 4-week maximum
  • Potential use of subcutaneous heparin for bridging of ambulatory hemodialysis patients
  • Treatment for 3 months for most patients with venous thromboembolism, including PE, followed by consideration of extended thromboprophylaxis
  • More specific recommendations for extended thromboprophylaxis for patients with DVT/PE, weighed against bleeding risk
  • Recommendations for ischemic heart disease, when anticoagulants are considered as part of the treatment regimen
  • Recommendations on use of new anticoagulants
  • Recommendations for post-arthroplasty venous thromboembolism prophylaxis
  • Further information on hypercoagulability evaluations.

Our guideline is an attempt to provide practical management strategies that are evidence based, and support our clinical practices. Though based on CHEST-2012 and other referenced information, we could not possibly do justice to the breadth of information in the well over a thousand electronic pages of the CHEST-2012 supplement or the additional reference material. The document is an attempt to provide guidance for the most common management situations facing a centralized anticoagulation management program and appropriately facilitate treatment decisions of our managers.

Harvard Vanguard Medical Associates: Clinical Guidelines and Practice Protocols – Revised 05/07/2014 Harvard Vanguard Medical Associates: Clinical Guidelines and Practice Protocols (Based on CHEST 2012 Recommendations), Alan Brush, MD

Chest – 2012 High Points and Pearls (Word document)
Chest – 2012 High Points and Pearls (Powerpoint presentation format)

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
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
Other Clinical Guidelines and Protocols
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
Coverage Policies
Coverage Policies Chart
Patient and Family Resources
Patient and Family Resources
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
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