Part III - 2021 Hospital National Patient Safety Goal Series: Reducing Anticoagulant-Associated Patient Safety Risks

In their effort to help hospitals improve performance and consistently provide high quality care, each year The Joint Commission publishes their National Patient Safety Goals (NPSG).

These reports gather information about emerging patient safety concerns and present sets of standards with measurable outcomes applicable to all Joint Commission-accredited hospitals and behavioral health care organizations.

In this series we have touched on goals related to identifying high suicide-risk patients, as well as prevention of wrong site, wrong patient, wrong procedure surgery errors. The third entry of our 2021 NPSG series centers on the reduction of patient safety risks associated with anticoagulant medication use.

As one of the most common medication classes to cause adverse drug events (ADEs), anticoagulants can lead to bleeding events, poor patient outcomes, and increased hospital costs. In this article we provide an overview of the eight required performance elements, along with steps you can take to reduce the risk of patient harm associated with anticoagulation therapy.

 Oral Anticoagulants Leading Cause of Adverse Drug Events in Older Adults

Anticoagulant medications are important in preventing and treating blood clots. However, oral anticoagulants, such as warfarin and direct oral anticoagulants (DOACs), are also the most common cause of ADEs in older adults, often leading to ER visits and hospitalizations. In 2017, bleeding events from oral anticoagulants led to over 235,000 emergency room visits.

In a five-year retrospective study conducted by Brigham and Women’s Hospital, they found that 70 percent of ADEs caused by anticoagulants were potentially preventable. Most commonly, the ADEs were due to missed medication doses and incorrect medication directions, such as the wrong drip rate or frequency.

Hospitals can avoid safety issues caused by incorrect anticoagulant dosage and usage by the creation and adherence of protocols designed to identify and communicate the associated risks. The following elements of performance outline eight anticoagulation therapy requirements that apply to all Joint Commission-accredited hospitals and critical access hospitals, as well as ambulatory and nursing care centers.

National Patient Safety Goal 03.05.01 Performance Elements

Element of Performance 1

The first element requires that hospitals use approved protocols and evidence-based practice guidelines to begin and maintain anticoagulation therapy.

Since anticoagulation medications are high-risk medications, organizations will be required to use updated and approved protocols and evidence-based practice guidelines. These guidelines are meant to ensure that the appropriate medication for the indication is selected, as well as the appropriate starting dose and frequency of the medication. Dosing adjustments may be required based on the patient’s age, renal function, liver function, drug-drug interactions, or drug-food interactions. These factors should be addressed in the protocols and practice guidelines.

Element of Performance 2

This element requires that hospitals use approved protocols and evidence-based practice guidelines for anticoagulation reversal and management of anticoagulant-associated bleeding events for each anticoagulant medication.

With bleeding being the most common complication from anticoagulants, having an anticoagulation reversal protocol that uses evidence-based practice guidelines is an integral part of anticoagulation therapy management. These protocols must include which reversal agent should be used based on the anticoagulant medication and the severity of the patient’s bleeding event.

Element of Performance 3

Hospitals are also required to use approved protocols and evidence-based practice guidelines for managing perioperative patients that are on oral anticoagulants. Such guidelines help minimize bleeding risks during surgery.

The perioperative anticoagulant management protocol should:

• Address when an anticoagulant should be stopped prior to surgery
• If a bridging medication should be used
• And at what dose the patient’s anticoagulant medication should be restarted

Element of Performance 4

The fourth element requires that hospitals have a written policy that addresses the need for baseline and ongoing laboratory tests for monitoring and adjusting anticoagulation therapy. Testing ensures that patients are on the correct dose and being monitored appropriately.

Element of Performance 5

Hospitals must establish a process to identify, respond to, and report adverse drug events, including adverse drug event outcomes.

This element also requires that hospitals have a process for:

• Evaluating their anticoagulation safety practices
• Taking actions to improve the safety practices
• And measuring the effectiveness of those actions in a hospital-defined time frame

Element of Performance 6

Providing patients and their families with proper medication education is required when anticoagulant medications are prescribed.

This medication education should include:

• The importance of adhering to the prescribed medication’s dose and schedule
• The importance of follow-up appointments and laboratory testing for monitoring, if needed
• Any potential drug-drug and/or drug-food interactions
• The potential for adverse drug reactions

Element of Performance 7

The seventh element requires that hospitals only use unit-dose products, prefilled syringes, or premixed infusion bags when available.

This requirement reduces the risk of dosing and medication errors that can occur and increases patient safety by improving the accuracy of the dose administered to the patient.

Element of Performance 8

Hospitals are required to use programmable pumps when heparin is administered through a continuous IV to provide consistent and accurate dosing.

Reducing the Risk of Patient Harm from Anticoagulation Therapy

Ensuring patient safety and improving patient outcomes as they relate to all medications, and especially anticoagulation medications, requires constant vigilance. To support hospitals in this task, MEDHOST provides solutions that help reinforce the necessary policies and protocols critical for meeting the eight elements of performance.

Once your facility has anticoagulation policies and protocols in place, you can create orders sets for physicians to use in the Order Management module of MEDHOST Physician Experience. These order sets standardize the ordering process for:

• Initiating anticoagulation therapy
• Ordering laboratory tests for monitoring
• Ordering anticoagulation reversal for bleeding events
• Stopping anticoagulants prior to surgery
• Restarting anticoagulants after surgery

Links to helpful online resources can also be added to order sets via Order Management, providing physicians with direct access to the evidence-based practice guidelines or other references. Some online resources helpful in creating anticoagulation policies and protocols may include:

• Anticoagulation Forum: Education and Guidance
• American Society of Health System Pharmacists
• Evidence-Based Management of Anticoagulant Therapy published by the American College of Chest Physicians

In addition, contained within pharmacy and nursing workflows, your clinicians can retrieve printable patient education materials. These documents include patient-focused instruction on:

• The importance of taking their medication
• How to take their medication
• Potential drug-drug and drug-food interactions
• Potential for adverse drug reactions

Also, some medications include medication guides that should be given to patients upon the prescribing of those specific medications.

To learn more about how MEDHOST helps support medication processes and helps your facility’s physicians and clinicians ensure proper usage, please reach out to us at inquiries@medhost.com or call 1.800.383.6278.