Reducing Medication Errors – Anticoagulation Medication Safety

Anticoagulants continue at or near the top of the list 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. 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.

In 2009, the Joint Commission implemented a National Patient Safety Goal (NPSG 03.05.01) to reduce the likelihood of patient harm associated with anticoagulation therapy, and revised the NPSG to address direct oral anticoagulants effective July 2019.

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, and continuing to share their updates. 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).

Atrius Health Anticoagulation Management Service Clinical Guideline and Practice Protocol – Revised July 2019, Alan Brush, MD

Message from Alan Brush, MD, MD, FACP, Chief, Anticoagulation Management Service, Atrius Health with July 2019 revisions:

We have created a new version of the Atrius Anticoagulation Management Service Guidelines and Practice Protocol to help support clinicians caring for patients on anticoagulation. Please remember, this document serves as a general management guideline based on a synthesis of multiple other recognized guidelines and cannot replace clinic judgment for any specific clinical situation.

The new version comes on the eve of our pilot for Centralized Management of DOACs in the Atrius Anticoagulation Program, which has been developed with the support of a grant from the Risk Management Foundation. In this version, we have incorporated updated information on:

1. DOAC management, including dosing for specific indications
2. Appropriate lab monitoring
3. Transitions to and from vitamin K antagonists
4. Perioperative care, interactions, and preferred choice of medication.

Note that our last update, April 2019, contained several changes related to external guidelines released in the previous year. Those changes included:

Appendix 1: Guideline for Establishing INR Goal and Duration of Treatment

Atrial Fibrillation with stable CAD: Per CHEST 2018, we recommend anticoagulation with a DOAC or adjusted dose VKA rather than an oral anticoagulant and aspirin.

Non Valvular Atrial Fibrillation

• We support the recommendation of CHEST 2018 and AHA/ACC/HRS-2019 to favor DOACs over VKA for this indication.
• Per CHEST 2018, we support the use of theSAMe-TT2R2 score to help identify patients about to begin anticoagulation likely to do well on VKA.
• Per CHEST 2018, we recommend against treatment with aspirin or oral anticoagulant for lone AF/flutter with CHA2DS2-VASc = 0 (or CHA2DS2-VASc = 1 for women)
• Per CHEST 2018, we recommend that oral anticoagulants should be considered for AF/flutter with CHA2DS2-VASc = 1 (or CHA2DS2-VASc = 2 for women), and do not recommend the use of aspirin for this group.

Atrial Fibrillation with ACS: Per AHA/ACC/HRS-2019: We recommend oral anticoagulation for patients with ACS and AF at increased risk of systemic thromboembolism (CHA2DS2-VASc ≥ 2), unless the bleeding risk exceeds the expected benefit.

Atrial fibrillation patients requiring oral anticoagulant undergoing PCI/stenting: we have provided updated options based on available major guidelines for this indication, including use of antiplatelets with oral anticoagulants and duration of dual/triple therapy.

Anticoagulation and pregnancy: we have provided new recommendations for use of warfarin at certain points during pregnancy.

Appendix 3: Guidelines for Maintenance Dose Adjustment and Monitoring:

Anticoagulation management around various cardiology procedures:

• If INR drops <2.0 prior to cardioversion, TEE may be conducted prior to cardioversion rather than postponing cardioversion.
• The majority of Electrophysiology (EP) procedures are now being done on uninterrupted warfarin.

Appendix 5: Guidelines for Managing Patients with High INR Values

• We have updated oral anticoagulation recommendations for patients with high risk of bleeding.
• We recommend the use of the HAS-BLED score to help address modifiable bleeding risk factors in all AF patients.

Appendix 10: apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Savaysa), and rivaroxaban (Xarelto)

• Per CHEST-2018, we support individualized decision making to determine the appropriate anticoagulation plan for patients with end-stage renal disease (CrCl < 15 or dialysis-dependent).
• We favor VKAs over DOACs when well-managed VKA (i.e. TTR > 65%) has been demonstrated.
• Note: this section has had the most replete update in specific recommendations in the July, 2019 version.

Appendix 11: Considerations for Anticoagulant Selection in Atrial Fibrillation and VTE Treatment

We have updated the definition of valvular AF to include patients with episodic or chronic AF in the absence of a mechanical heart valve or moderate to severe mitral stenosis.

Appendix 12: Indications and considerations for combined anticoagulant/antiplatelet therapy

We recommend the use of a PPI to decrease the risk of upper gastrointestinal bleeding whenever using combined anticoagulant/antiplatelet therapy.

Appendix 13: Heparin-Induced Thrombocytopenia (HIT)

We have updated HIT management guidelines to include potential use of DOACs.

Safely Managing Patients on Warfarin-November 4, 2008 Program

The information shared at the Coalition’s 2008 programs may help clinicians and administrators of anticoagulation services adopt practices and tools 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

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