The Institute for Healthcare Improvement, (www.ihi.org), an independent not-for-profit organization helping to lead the improvement of health care throughout the world, introduced proven best practices across the country as part of its 100,000 Lives Campaign in 2005 to reduce the number of unnecessary deaths in hospitals. The IHI will complete in 2008 its two-year 5 Million Lives Campaign, aimed to protect patients from millions of incidents of medical harm in U.S.
The IHI has established three principles to ensuring a safe system in order to prevent medical errors:
- Prevent - Errors and harm through standardization.
- Detect - Errors and harm by having appropriate checks and adequate monitoring of patients.
- Mitigate - Errors and harm: have mechanisms in place to prevent or minimize harm that may be caused by an error.
The following are links to several protocols the IHI recommends to reduce adverse drug events involving anticoagulants. For an full list of recommendations, please visit www.ihi.org.
When pharmacists manage an anticoagulation service, they assume all responsibility for implementation and maintenance of anticoagulant therapy. Physician orders determine that the patient will receive the therapy and specify the desired range for the International Normalized Ratio (INR) value. But pharmacists determine the appropriate initial dose and then review clinical information daily to determine whether adjustments are needed. Allowing pharmacists to manage an anticoagulation service results in greater efficiency for pharmacists, nurses, and physicians, who don't have to spend time making phone calls to report lab values or check for changes in dosing orders. The pharmacists make adjustments to the dose in a timelier fashion - a benefit to the patient that reduces the chance of an adverse drug event.
Heparin's potency means that even small errors in preparing doses or solutions can lead to serious adverse drug events and cause significant harm to patients. By preparing all doses and solutions in the pharmacy, an organization can decrease the chance of errors occurring. That is, the fewer staff members who are involved in preparing doses and solutions, the easier it is to maintain competency and consistent practice. Heparin doses and solutions should arrive on patient care units in ready-to-use form, with no need for further manipulation by nursing staff.
Using pre-mixed solutions reduces the possibility of an adverse drug event due to a mixing error. Pre-mixing also saves time for pharmacy and nursing staff.
The flow rate of heparin solution affects the dose of heparin that is actually administered. Dosing charts that list the appropriate flow rates for various heparin doses help staff members quickly select the proper flow rates without having to recall information from memory or do manual calculations.
Laboratory values that indicate coagulation levels in the blood help determine the proper dose of anticoagulant medications. Physicians can direct nurses or pharmacists to titrate or adjust anticoagulant dosages in order to maintain a certain range of those laboratory values. This method allows for more timely adjustments to dosages and eliminates the need for a physician's order for every dose adjustment.
When patients receive thrombolytics or G2b/3A inhibitors while they are receiving anticoagulants, they face an increased risk of bleeding. Prescribers must adjust the anticoagulant dosage appropriately to reduce that risk as much as possible. Computerized prescriber order entry systems can provide a reminder of this drug interaction and prompt the prescriber to adjust anticoagulant doses accordingly.
Programmable pumps provide safety features that control the amount of intravenous solution delivered per hour to a patient—safety features that are not available with hanging intravenous solution bags alone. Pumps control the amount of solution delivered and help prevent inadvertent under- or overdosing. Two clinical staff members should perform independent double-checks to make sure the pump settings are correct and consistent with current orders.
Consistent timing of anticoagulant doses is an important part of minimizing the risk of anticoagulant-related adverse drug events. However, busy staff members can easily miss administration times. Alarm clocks or timers with either audible or visible alarms can remind staff members when anticoagulant doses are due. Ensure that alarm devices are placed in locations where staff members will hear or see them.
Keeping all of the information about a patient's anticoagulant therapy organized in one place helps the clinical staff plan and assess therapy. Flowsheets are a great way for staff members to record orders, doses administered, flow rates, laboratory values, and other important data. A flowsheet can help a prescriber assess a patient's response to therapy and consider order changes. A comprehensive flowsheet saves time for staff members because they do not have to look in multiple places for the information they need.
Use normal saline solution instead of heparin to flush peripheral intravenous lines. Heparin solution should never be used because extra inadvertent doses of heparin through the intravenous lines can lead to adverse drug events, especially when patients are receiving other anticoagulant therapy or are at risk for bleeding.
An arterial line will usually have a pressurized bag of intravenous solution attached. Whenever clinicians draw blood from the arterial line, or whenever they administer medications through the arterial line, they flush the line afterward with solution from this same pressurized bag to ensure that the blood does not clot in the line or that the medication reaches the patient.
There is also always a risk of inadvertent flow of extra solution through the line from the pressurized bag of solution. If the bag contains a heparin solution, the patient may receive an unintended dose of heparin, which could lead to an adverse drug event. Use normal saline solution bags instead of heparin solutions, as saline is equally good for flushing blood and medications through arterial lines.
When a patient receives anticoagulant medications, the values of his or her laboratory coagulation tests tell clinicians whether dose adjustments are warranted. Laboratory values that are significantly out of range, or trending in an undesired direction, signal an increased risk of an adverse drug event. Therefore, it is critical that the results of these laboratory studies be available for clinician review in a timely fashion. The goal should be to have all coagulation test results available on the patient record within two hours from the time of sample collection. This may not be possible for all organizations, depending on whether or not the analyzing laboratory is on site or electronic reporting mechanisms are available. In those cases, use point-of-care testing equipment to conduct analyses at the patient's bedside, which provides immediate results.
Clinicians use International Normalized Ratio (INR) values to set anticoagulant doses. When they rely on different types of testing equipment to measure INR values, variations in the equipment may lead to variations and errors in the INR readings. Furthermore, staff members find it more difficult to maintain competence with several different types of equipment than with one standard type. Errors in testing or interpreting INR values can lead to incorrect dosing of anticoagulants and result in adverse drug events. Select one standard type of INR testing equipment and use it throughout your organization to decrease the risk of such errors.