Adverse Drug Events – Excessive Anticoagulation Olympia Medical Center AIM Statement Next Steps

Adverse Drug Events – Excessive Anticoagulation
Olympia Medical Center
Los Angeles, CA
November, 2014
AIM Statement
Run Chart
Reduce ADE – Excessive Anticoagulation
from 2011 baseline
by 40% by December 2014.
(Baseline = 4.87, AIM = 2.92 by 12/14)
2014 YTD Performance: 0.38
• Expansion of discharge medication
counseling procedures.
• Develop relationship(s) with anticoagulation
clinics surrounding our hospital to provide
better continuity of care for patients.
discharged on warfarin therapy.
Interventions
• Communicate with other area hospitals
utilizing CPOE and barcoding technology to
make sure safeguards in place for high risk
medications are optimized.
Phase 1:
• An Anticoagulation Management
Performance Improvement Team was
created in late 2011.
• Clinical Pharmacist monitoring of all patients
receiving warfarin, enoxaparin, intravenous
heparin, and other oral anticoagulants on
daily basis, regardless of “per pharmacy”
order status.
• Creation of an easily accessible report for
Dietary Department that lists all patients on
warfarin therapy to provide appropriate
reinforcement of the importance of a
consistent diet.
• A monthly report is reviewed by the Director
of Pharmacy that lists administration
dates/times of warfarin and its reversal agent,
phytonadione to be analyzed case by case.
• Periodic medication use evaluations
performed by the Pharmacy Department to
ensure proper use of our pharmacist driven
warfarin protocol.
Phase 2:
• Warfarin was removed from automated
medication dispensing cabinets and
implementation of barcode technology
decreased potential for incorrect dose
administration.
• Automatic INR “pop-up” built into medication
ordering system to alert providers and
pharmacists of patient’s most recent INR.
Next Steps
Team Members
Data Source: Comprehensive Data System-HRET as of 09-09-2014
Lessons Learned
• It is essential that all patients on full anticoagulation be
monitored by pharmacists, not only the patients on
pharmacy driven protocols.
• Case by case analysis is essential for all patients requiring
warfarin reversal to pinpoint system errors and formulate
improvement plans.
• Anticoagulation must be included as a key topic in yearly
clinical pharmacist competency assessment.
• Multidisciplinary involvement/cooperation essential for
reduction in excessive anticoagulation.
Resources
• HQI ADE Harm Elimination Toolkit is available on the HQI
website at hqinstitute.org < Tools and Resources.
• Questions: Contact Mahsa Farahani, Project Manager, HQI
at 916-552-7521, email [email protected].
• Anticoagulation Performance Improvement
Team:
• Director of Pharmacy: Dr. Annette
Marquez, PharmD
• Chair of the Pharmacy & Therapeutics
Committee: Dr. Alfred Rahban, MD
• Informatics Pharmacist: Dr. Lisa
Preimesberger, PharmD
• Clinical Pharmacist: Dr. Jordan Yingling,
PharmD
• Director of Case Management: Quiana
Hines, RN
• Registered Dietitian: Emilia Janeke, RD