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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 Atrius Health 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 Atrius Health (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, Atrius Health:

Below is a link to the newly revised AMS Guidelines, including a synthesis of guidelines from the following sources:

  1. Antithrombotic and Thrombolytic Therapy, 9th Edition: ACCP Guidelines; vol. 141 supplement CHEST-9) - 2012
  2. Kearon, Clive et al; Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. CHEST. February 2016, Vol 149, No. 2
  3. European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation - 2016
  4. Atrial Fibrillation - European Society of Cardiology - 2016
  5. Anticoagulation for valvular heart disease - ACC.AHA-2015
  6. Anticoagulation for valvular heart disease - ACC/AHA-2017 focused update
  7. ACC Consensus Pathway for Perioperative Management of non-valvular AF - 2017
  8. Common Procedures and Associated Procedural Bleed Risk - ACC - 2016

When varying recommendations appear in these guidelines, we have suggested alternative approaches, or have explained our rationale from taking one or other position.

  1. We continue to favor continuing warfarin for all patients where it is the primary recommendation over newer oral anticoagulants (e.g. patients with mechanical heart valves), and in patients continuing warfarin with a reasonable time in therapeutic range over the preceding year. We have found that cost issues makes the use of these agents less acceptable to many patients who are already doing well on warfarin.
  2. We 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. Most of our patients test every 4 weeks, though we permit testing every 8 weeks for stable patients, not the “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 includes a large number of updates, including:

  • Expansion of information on DOACS, including peri-procedural recommendations and transitioning between anticoagulants.
  • Recommendations for dual antiplatelet-anticoagulant treatment, as well as appropriate precautions.

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.

Atrius Health Anticoagulation Management Service Clinical Guideline and Practice Protocol — Revised 03/20/2017, 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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