ISS-Ehealthnewsletter-0515 (3)
2
NEWS MAY 2015 Updates and reminders: • Meditech Monthly Downtime: May 20th, 0230 – 0530 Physician Help Desk: Phone: 689-5432 or x35432 Atrium hours: Monday-Friday 8:00 a.m.–5:00 p.m. Rounding Times are 9:00–10:00 a.m. ON CALL support for nights and weekends for CPOM issues and questions Double Trouble – Inappropriate Dual Anticoagulant Therapy Recently we have seen an upswing in the number of medication errors involving oral anticoagulants. Examples of these errors include: • Starting apixaban (Eliquis) on a patient with concurrent subcutaneous heparin • Continuing warfarin (Coumadin) on admission when INR is supratherapeutic Anticoagulants are inherently high-risk medications that can result in serious patient safety events. Whether you are a prescriber, pharmacist, or nurse, there are several steps you can take to ensure proper use of these drugs: • If a patient takes warfarin, check INR results before ordering / verifying / administering any anticoagulant • Questioning anytime multiple anticoagulants are prescribed • Novel oral anticoagulants take effect much sooner than warfarin; when switching between anticoagulants, time the doses appropriately (Table 1 on right) Table 1: Dose timing on anticoagulant switch Converting From: Enoxaparin Fondaparinux Dabigatran Rivaroxaban Apixaban Warfarin Converting From: Heparin (IV) Heparin (SQ) Fondaparinux Dabigatran Rivaroxaban Apixaban Warfarin Converting From: Heparin (IV) Heparin (SQ) Enoxaparin Dabigatran Rivaroxaban Apixaban Warfarin Converting From: Heparin (IV) Heparin (SQ) Enoxaparin Fondaparinux Rivaroxaban Apixaban Warfarin Converting From: Heparin (IV) Heparin (SQ) Enoxaparin Fondaparinux Dabigatran Apixaban Warfarin Converting From: Heparin (IV) Heparin (SQ) Enoxaparin Fondaparinux Dabigatran Rivaroxaban Warfarin Converting From: Heparin (IV) Enoxaparin Fondaparinux Dabigatran Rivaroxaban Transitioning To Heparin (IV or SQ) Initiate at the time of the next scheduled dose Discontinue Warfarin and start Heparin when INR is below the therapeutic range Transitioning to Enoxaparin Initiate as the same time of discontinuation of the heparin continuous infusion Initiate at the time of the next scheduled dose Discontinue Warfarin and start Enoxaparin when INR is below the therapeutic range Transitioning to Fondaparinux Initiate as the same time of discontinuation of the heparin continuous infusion Initiate at the time of the next scheduled dose Discontinue Warfarin and start Fondaparinux when INR is below the therapeutic range Transitioning to Dabigatran Initiate as the same time of discontinuation of the heparin continuous infusion Initiate at the time of the next scheduled dose Discontinue Warfarin and start Dabigatran when the INR is <2.0 Transitioning to Rivaroxaban Initiate as the same time of discontinuation of the heparin continuous infusion Initiate at the time of the next scheduled dose Discontinue Warfarin and start Rivaroxaban when the INR is <3.0 Transitioning to Apixaban Initiate as the same time of discontinuation of the heparin continuous infusion Initiate at the time of the next scheduled dose Discontinue warfarin and start Dabigatran when the INR is <2.0 Transitioning to Warfarin Bridge Therapy: Discontinue after a minimum of 5 days duration and achievement of an INR >2.0 (Both criteria must be met). Based on renal function, start warfarin a certain number of days before discontinuing dabigatran: CrCl ≥50 mL/min = 3 days ; 30-50 mL/ min = 2 days; 15-30 mL/min = 1 day; <15 mL/min, no recommendations can be made. At the next scheduled dose of the oral anticoagulant, discontinue all oral anticoagulants and begin bridge therapy with parenteral anticoagulant, begin warfarin, and continue the parenteral anticoagulant until the INR reaches an acceptable range.
-
Upload
megan-lindsay -
Category
Documents
-
view
42 -
download
0
Transcript of ISS-Ehealthnewsletter-0515 (3)
NEWSMAY 2015
Updates and reminders:• Meditech Monthly Downtime: May 20th, 0230 – 0530
Physician Help Desk:Phone: 689-5432 or x35432Atrium hours: Monday-Friday 8:00 a.m.–5:00 p.m. Rounding Times are 9:00–10:00 a.m.ON CALL support for nights and weekends for CPOM issues and questions
Double Trouble – Inappropriate Dual Anticoagulant TherapyRecently we have seen an upswing in the number of medication errors involving oral anticoagulants. Examples of these errors include:
• Starting apixaban (Eliquis) on a patient with concurrent subcutaneous heparin
• Continuing warfarin (Coumadin) on admission when INR is supratherapeutic
Anticoagulants are inherently high-risk medications that can result in serious patient safety events. Whether you are a prescriber, pharmacist, or nurse, there are several steps you can take to ensure proper use of these drugs:
• If a patient takes warfarin, check INR results before ordering / verifying / administering any anticoagulant
• Questioning anytime multiple anticoagulants are prescribed
• Novel oral anticoagulants take effect much sooner than warfarin; when switching between anticoagulants, time the doses appropriately (Table 1 on right)
Table 1: Dose timing on anticoagulant switchConverting From:EnoxaparinFondaparinuxDabigatranRivaroxabanApixabanWarfarin
Converting From:
Heparin (IV)Heparin (SQ)FondaparinuxDabigatranRivaroxabanApixabanWarfarin
Converting From:
Heparin (IV)Heparin (SQ)EnoxaparinDabigatranRivaroxabanApixabanWarfarin
Converting From:
Heparin (IV)Heparin (SQ)EnoxaparinFondaparinuxRivaroxabanApixabanWarfarinConverting From:
Heparin (IV)Heparin (SQ)EnoxaparinFondaparinuxDabigatranApixabanWarfarinConverting From:
Heparin (IV)Heparin (SQ)EnoxaparinFondaparinuxDabigatranRivaroxabanWarfarinConverting From:Heparin (IV)EnoxaparinFondaparinuxDabigatran
Rivaroxaban
Transitioning To Heparin (IV or SQ)Initiate at the time of the next scheduled dose
Discontinue Warfarin and start Heparin when INR is below the therapeutic rangeTransitioning to EnoxaparinInitiate as the same time of discontinuation of the heparin continuous infusion
Initiate at the time of the next scheduled dose
Discontinue Warfarin and start Enoxaparin when INR is below the therapeutic rangeTransitioning to FondaparinuxInitiate as the same time of discontinuation of the heparin continuous infusion
Initiate at the time of the next scheduled dose
Discontinue Warfarin and start Fondaparinux when INR is below the therapeutic rangeTransitioning to DabigatranInitiate as the same time of discontinuation of the heparin continuous infusion
Initiate at the time of the next scheduled dose
Discontinue Warfarin and start Dabigatran when the INR is <2.0Transitioning to RivaroxabanInitiate as the same time of discontinuation of the heparin continuous infusion
Initiate at the time of the next scheduled dose
Discontinue Warfarin and start Rivaroxaban when the INR is <3.0Transitioning to ApixabanInitiate as the same time of discontinuation of the heparin continuous infusion
Initiate at the time of the next scheduled dose
Discontinue warfarin and start Dabigatran when the INR is <2.0Transitioning to WarfarinBridge Therapy: Discontinue after a minimum of 5 days duration and achievement of an INR >2.0 (Both criteria must be met).
Based on renal function, start warfarin a certain number of days before discontinuing dabigatran: CrCl ≥50 mL/min = 3 days ; 30-50 mL/min = 2 days; 15-30 mL/min = 1 day; <15 mL/min, no recommendations can be made. At the next scheduled dose of the oral anticoagulant, discontinue all oral anticoagulants and begin bridge therapy with parenteral anticoagulant, begin warfarin, and continue the parenteral anticoagulant until the INR reaches an acceptable range.
5/2015
New Changes Coming to Ultra Sound Order Entry ProcessThe “US Abdomen (USI)” order now contains required information:
The “US Abdomen RUQ (USI)” now contains additional information:
The “US Abdomen Limited (USI)” order now contains required information:
REQUIRED
REQUIRED
C O M I N G I N M I D M AY
