Preventing Surgical Complications

Prevent Harm from High Alert Medication- Anticoagulants in Primary Care

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Presenter:

Introduction

• The 1000 lives campaign focuses on the implementation of proven interventions to save lives and reduce harm to patients in NHS Wales

• The aim of this intervention is to reduce the likelihood of patient harm associated with the use of anticoagulation therapy in primary care

Preventing harm from High Alert Medication- Anticoagulants

Rationale

• In Wales there are more than 20,000 patients taking oral anticoagulants in primary care

• 1° care - Anticoagulants are one of the classes of medicines most commonly associated with fatal medication errors.

• 2° care- Warfarin is one of the ten drugs most frequently associated with dispensing errors.

Preventing harm from High Alert Medication- Anticoagulants

Rationale

• The NHS Litigation Authority has reported that medication errors involving anticoagulants fall within the top ten causes of claims against NHS trusts

• Anticoagulants are one of the classes of medicines most frequently identified as causing preventable harm and admission to hospital (Pirmohamed M et al. 2004, Howard RL et al. 2007)

Preventing harm from High Alert Medication- Anticoagulants

NPSA Risk Assessment

• NPSA risk assessment 2006 found:–120 deaths–480 serious harms–anticoagulants the second therapeutic

group (after opiates) causing the most deaths and severe harm

Preventing harm from High Alert Medication- Anticoagulants

Why such a problem?Adverse drug events are common with Warfarin due

to-

• Complexity of dosing and monitoring

• Patient compliance

• Biological variation in response to treatment

• Numerous drug interactions

• Dietary interactions that can affect drug levels

Preventing harm from High Alert Medication- Anticoagulants

NPSA Recommendations• Following the NPSA Risk Assessment

2006 a series of safer practice recommendations were issued, along with Alert 18 and an NPSA anticoagulant audit for all primary and secondary care providers to use

Preventing harm from High Alert Medication- Anticoagulants

The Safer Practice Recommendations• Training and work competencies required• The need to update procedures and protocols• The need for audit of anticoagulant services

safety indicators• The need for improved information and

counselling for patients

Preventing harm from High Alert Medication- Anticoagulants

Where are we now?

• Anticoagulant management has been adopted as part of the SPI 2 initiative taking place in participating Welsh hospitals

• The NPSA Patient Safety Alert 18 is being implemented at present throughout primary and secondary care in Wales.

Preventing harm from High Alert Medication- Anticoagulants

Campaign Aim

• Draw current processes together• Measure implementation of process

changes• Evaluate what has achieved an impact• Support clinical teams in spreading those

elements in a managed way

Preventing harm from High Alert Medication- Anticoagulants

How?

• Standardise and simplify core medication processes in known high-risk areas,

• redesign delivery systems using proven human factors principles

• partnering with patients• create safety cultures that minimise blame and

maximise communication

Preventing harm from High Alert Medication- Anticoagulants

General principles

• Design processes to prevent errors and harm.

• Design methods to identify errors and harm when they occur.

• Design methods to mitigate the harm that may result from the error.

Preventing harm from High Alert Medication- Anticoagulants

Measurement StrategiesSuccessful measurement is a cornerstone of

successful improvement.

• Use sampling to make measurement efficient.

• Integrate measurement into people’s daily routine.

• Plot data on the measures over time, and post results so that teams can see their progress.

Preventing harm from High Alert Medication- Anticoagulants

Process Measures

• % Patients Receiving Anticoagulant with Treatment Appropriately Managed According to Protocol

• % of Patients Receiving Anticoagulant without appropriate written clinical information e.g. indication, target INR, stop date

Preventing harm from High Alert Medication- Anticoagulants

Evidence

• Failure to implement professional guidelines concerning the prescribing, counselling, monitoring and administering of anticoagulants is an important underlying cause of harm (NPSA 2006)

Preventing harm from High Alert Medication- Anticoagulants

Outcome Measures

• Adverse Drug Events Related to Anticoagulant in previous month with Anticoagulant Administered

• % of Patients Receiving Warfarin with INR Outside Protocol Limits

Preventing harm from High Alert Medication- Anticoagulants

Outcome Measures

• % of Patients Receiving Warfarin with INR >5 but <8

• % of Patients Receiving Warfarin with INR >8

• % of Patients Receiving Warfarin with no INR recorded

Preventing harm from High Alert Medication- Anticoagulants

Evidence• It is accepted as a good standard of care if

patients are within the target range of INR 60% of the time (Machin, 2002).

• Risk of haemorrhage whilst on long term anticoagulation varies between 1 and 15% per annum and the risk of death increases with increasing INR (Oden and Fahlen 2002).

Preventing harm from High Alert Medication- Anticoagulants

Measures• These measures do not measure harm

directly, serve as more-easily-collected proxies for negative clinical outcomes associated with high-alert medications.

• Measures can and should be used as starting points in case-by-case investigations of how the care system may have failed.

Preventing harm from High Alert Medication- Anticoagulants

Audit+ tool• data can be plotted monthly to monitor how the service is

improving and where patterns indicate an area for further change.– Number of patients on anticoagulants – % INR in range– % INR over 5– % INR over 8– % with no INR recorded– % recorded with ADR in last month

Preventing harm from High Alert Medication- Anticoagulants

Summary

• NPSA alert underway, but we can still work to improve safety with anticoagulants.

• Consider key areas after implementation – review success of implementation – consider using PDSA to prove or improve safety of Warfarin.

Preventing harm from High Alert Medication- Anticoagulants

Preventing harm from High Alert Medication- Anticoagulants

PDSA• Small changes, one patient, one list, one team• Spread if did work• Measure – did it work, if not try something different• Identify a pilot population• Measure• Are you already doing it? – measure compliance

Preventing harm from High Alert Medication- Anticoagulants

Day 2

• Review the interventions made• Decide which you are taking forward• Local action plan• Identify first test of change• What are the challenges