Improving management of patients on oral anticoagulants risk benefit assessment for patients requiring oral anticoagulation alternative treatments to oral anticoagulation. The current practice to treat acute venous thromboembolism vte would be to initiate warfarin in conjunction with a parenteral low molecular weight heparin lmwh, dosed according to body weight. This patient safety alert has been developed in collaboration with the. Initial warfarin dosing should be tailored based on patient bleed risk, potential sensitivity to warfarin, indication, goal inr range, and if potential drug interactions are present. National patient safety agency npsa recommendations state that key. Agency npsa states that there is evidence that anticoagulant. The top ten prescribing errors in practice and how to. Warfarin guidelines for primary care nhs better health. The kings thrombosis centre is a leading multidisciplinary clinical and research group dedicated to the diagnosis and treatment of hypercoagulable conditions. Slow induction of anticoagulation in patients with atrial fibrillation. Prescribing and monitoring of warfarin nhs cambridgeshire and. Warfarin has a narrow therapeutic index and regular titration of the dose against the anticoagulant effect in the blood, as assessed by the inr, is essential. Ensured that it systems are compliant with the guidance both gp and pharmacy ensured there are distinguishable supplies of 2. Safe use of warfarin in primary care health and social care board.
The patient should be maintained within their therapeutic range, as documented in table1. Warfarin management guideline this guideline is intended to inform medical and nursing staff employed within the clinical haematology department. The national patient safety agency npsa advises that compliance aids may be helpful, but that in their absence the risk of using warfarin may outweigh the benefits. Warfarin dose is prescribed according to local guidance written fv guidance or other approved c. The national patient safety agency npsa website has now been archived. The national patient safety agency npsa has identified oral anticoagulants and heparin as major causes of adverse events and hospital admission. This is a guide only use approved clinical decision support software cdss. The individual product information for any new concomitant therapy should be consulted for specific guidance on warfarin dose adjustment and therapeutic monitoring. Components of an excellent anticoagulation service for patients with atrial fibrillation. This is a guide only use approved clinical decision support software cdss but. Nhs england and nhs improvement national patient safety alerts. These guidelines are to guide the prescribing of warfarin where no computer software is available or where advice is sought.
Local guidance to anticoagulation monitoring enhanced service. If you manage a large anticoagulation service and want to improve productivity, patient safety and patient experience, take a look at what the dawn. This document is intended to provide guidance to all multidisciplinary staff. Inclusion of warfarin tablets in monitored dosing systems mds is not recommended 10. Pharmacists with a special interest in anticoagulation. This resource is one of a series produced by the clinical team of the east and south east england specialist pharmacy services. The prescriber can provide a patient specific direction on warfarin dose. This service specification incorporates the available guidance to support. This service specification incorporates the available guidance to support safe. Fda issues new guidance for clinical and patient decision. This enhanced service specification for the provision of warfarin anticoagulant management outlines the more specialised. According to its research, anticoagulants are implicated in 810 per cent of preventable drugrelated admissions 1,2 and are increasingly associated with adverse incidents, including some.
Details of any local protocol guidance followed andor c. The output of the npsa is to be used with the neocis guidance system. The national nhs patient safety team is now part of nhs improvement. Warfarin is not usually indicated for ischaemic stroke without atrial fibrillation. This section in the how to guide for reducing harm from high risk medicines provides a worked example for the first of these three actions to demonstrate the method. Pharmacists providing an anticoagulant monitoring service should be familiar with all of this guidance. Valley warfarin guidance including management of over anticoagulation. Managing patients who are taking warfarin and undergoing. Warfarin monitoring aims to stabilise the inr within set limits to help prevent serious side effects. Furthermore, there were 217 prescribing errors claims closed by the medical defence union, one of the several medical defence organisations in the uk that provides medical indemnity, between 2011 and 2015. The data can still be collected, if desired for internal use. Since the nrls was set up in 2003, the culture of reporting incidents to improve safety in healthcare has developed substantially. Details of our current reporting and alerting functions can be found below.
Appendix 1 nhs forth valley warfarin guidance including management of over anticoagulation adapted from lothian. The pct accredited the first two phwsis in england in april 2008. Sep 30, 2015 a preprinted inr request form has now replaced the yellow book in east and north hertfordshire nhs trust following a transformation of pathology services. Anticoagulation management american college of cardiology. This guidance applies to all healthcare sectors, including social care settings. There is evidence that anticoagulant dosing software helps to maintain the. All anticoagulant management within rch occurs under the supervision and guidance of a consultant haematologist. Warfarin has a narrow therapeutic range and care is required with all concomitant therapy. It is recommended treatment takes place in the morning at the beginning of the week when rebleeding problems can. The npsa recommends use of constant daily dosing and not alternate day dosing.
Patients prescribed warfarin longterm should be assessed at least annually and have documentation of a gold standard annual. Practitioners managing oral anticoagulation with warfarin should meet the. Any primary care healthcare provider wishing to use a nearpatient inr testing device must ensure that the equipment is regularly checked using both an internal and external quality control. National patient safety agency npsa alerts alerts issued prior to april 2012 alerts issued prior to 1 april 2012 are available via the archived national patient safety agency npsa website please note.
How to manage warfarin therapy australian prescriber. The npsa provides preoperative planning for dental implantation procedures. From the information gathered, three potential solutions were identified. The npsa has worked with health professionals, patient groups, the pharmaceutical industry and medical and pharmaceutical software suppliers to identify and develop solutions. This morning, the food and drug administration released highly anticipated guidance on clinical and patient decision support that has been in the works at the agency for several years, advising the digital health community about how it plans to regulate software that offers recommendations or feedback to its usersboth healthcare professionals, and patients and caregivers. This veterans health administration vha directive provides guidance for establishment of a program for use of patient selftesting pst for prothrombin pt by international normalized ratio inr in monitoring of patients on anticoagulation therapy using warfarin.
Warfarin is usually the oral anticoagulant of choice, but others such as phenindione are occasionally used. Guidance on the safe use of warfarin in primary care. Report from the anticoagulant working group, september 2007 page 2. Warfarin management adult ambulatory clinical practice. This page forms part of a resource on medication related patient safety alerts issued by the national patient safety agency npsa between 2002 and 2012 more details can be found here you will also find links to. A range of guidance and resources is also available from the national patient safety agency and the all wales medicines strategy group6. The npsa patient safety alert includes guidance and recommendations that are relevant to community pharmacy. Dawn ac anticoagulation software dawn clinical software. A preprinted inr request form has now replaced the yellow book in east and north hertfordshire nhs trust following a transformation of pathology services. Critical assessment of evidence to help you make decisions. This functionality should be utilised, if available, by all organisations involved in prescribing or dispensing of anticoagulants 2.
Further information can be found on the npsa website. To understand the use of anticoagulation in stroke prevention in af 3. Oral anticoagulant warfarin guidelines oxford university hospitals. Past npsa alerts and guidance remain available on the archived website but please use these materials with caution. The neocis planning software application npsa for 3rd party pcs is intended to perform the planning preoperative phase of dental implantation surgery. Foster, pharmacist approved by wirral drug and therapeutics committee. Teams working on this intervention may refer to this and information in the accompanying campaign document, introduction to implementing campaign interventions, to work. Obtain an inr measured no more than 72 hours before the dental procedure. This ensures that the dose of warfarin will be the same for each day of the week.
Nhs golden jubilee national hospital as the board treats patients on an elective basis, the specialties covered means that no patients are commenced on this treatment whilst in the gjnh. D software used, as well as a description of the arrangements for internal and external assurance. When possible, a single strength warfarin tablet should preferably be prescribed so that doses are multiples of one tablet. Npsa patient safety alert 18 in 2007 acknowledged warfarin as a.
Providers should normally use computer dosing software systems awmsg warfarin monitoring11. When a patient is to be commenced on warfarin or is admitted on warfarin the indication for warfarin, target inr and length of treatment should be documented in the medical notes. It is recommended treatment takes place in the morning at the beginning of the week when rebleeding problems can be managed during the working day and working week. Patient and carer groups have informed the npsa that warfarin regimens with the.
The npsa has found that patients taking warfarin prefer their dose to be prescribed. The national patient safety agency npsa, with support from the british dental. In 2007 the national patient safety agency npsa issued recommendations for. The national patient safety agency npsa has also issued guidance on making anticoagulant therapy safer, with a range of associated resources for healthcare professionals and patients. Fairbairnsmith l, cope w, robinson b, kamali f, wynne h. Prescribing guidelines for the management february 2018. The department of healths pharmacists with special interests phwsis framework for england has been used successfully by bradford and airedale teaching primary care trust to upskill pharmacists to provide anticoagulation services to patients in the community. The alerts and guidance that remain available on the archived npsa. Only accredited practitioners who meet the service specification and sign up to the service level agreement should provide this service. The inr should be measured daily for the first five days. Newer oral anticoagulants are now available, but cost and licensing issues will mean that warfarin will continue to be used for some time yet. Pirmohamed m, james s, green c, scott ak, walley tj, et al.
Guidance for the practical management of warfarin therapy in. A reporting form should be completed and sent to the relevant repositories. Our patient safety team was the first national body accredited to issue national patient safety alerts by the national patient safety alerting committee napsac. Inrstar complies with the npsa guidelines by adopting the following rules when calculating a suggested warfarin dose. There is evidence that anticoagulant dosing software helps to maintain the inr levels. Evidence context place in therapy of directacting oral anticoagulants doacs the 4doacs currently licensed in the uk are apixaban, dabigatran etexilate, edoxaban and rivaroxaban. The national reporting and learning system nrls is a central database of patient safety incident reports. Review august 2015 page 1 of 16 clinical guidance anticoagulant oral therapy prescribing guidelines. Using software to facilitate positive, sustainable change. Apr 15, 20 warfarin therapy should be stopped five days before major surgery and restarted 12 to 24 hours postoperatively. Anticoagulants, including directacting oral anticoagulants. Reducing harm from highrisk medicines nursing times. How to look after patients on anticoagulant therapy. Nice guidance is expected in 2014 when published these local guidelines will be updated inr testing a recognised laboratory service must be used.
The treatment guidance software, tooguide trus, is a standalone device that enables. Guideline on oral anticoagulation with warfarin this guideline is intended to be used in derbyshire to support the primary care led inr monitoring service commissioned in derbyshire. Clinical guidance anticoagulant oral therapy prescribing guidelines this guidance covers. Warfarin anticoagulation is widely used for many clinical indications. The national patient safety agency npsa is recommending that nhs. Learning from patient safety incidents nhs improvement. Thirtyfive consecutive patients attending an anticoagulant monitoring clinic of newcastle upon tyne hospitals nhs foundation trust for at least 7 months were approached and asked to participate in assessing the acceptability and the effect upon their knowledge of the npsa oral anticoagulant therapy information. If no information is provided the possibility of an interaction should be considered. Contains many of the statistics specified by the npsa safety alert, which typcially locations are required to provide as part of their audit. Issue 1 failure to address the population problem of poor.
The national patient safety agency npsa recommendations state that key information about patients on warfarin should be clearly recorded. Anticoagulation guidelines kings thrombosis centre. Archived npsa alert actions that can make oral anticoagulant therapy safer 2007 published 28th march 2007, updated 22nd august 2018 medicines use and safety team. The npsa recommended that these actions were to be implemented in england and wales by march 2005. Effect of provision of the nhs npsa oral anticoagulant. This report calculates the following npsa statistics over a specified date range, filtered by location.
The npsa recommends that prescribing and dispensing software should include functionality to enable details of the interacting medicines and the request for the. Updated guidelines on outpatient anticoagulation american. The npsa recommends that prescribing and dispensing software should include functionality to enable details of the interacting medicines and the request for the patient to arrange additional inr tests to be recorded. Computer clinical decision support software cdss such as dawn. Oral anticoagulation with warfarin introduction all practices are expected to provide essential and those additional services they are contracted to provide to all their patients. Other prescribed medicines advise the patient that additional blood tests may be necessary. Effect of provision of the nhs npsa oral anticoagulant therapy patient information pack upon patients knowledge and anticoagulant control. Anticoagulants west suffolk clinical commissioning group. See ccg guidance on prescribing and monitoring of warfarin at the link below.
Nice has issued technology appraisal guidance on the use of doacs in several clinical settings. This guidance is available on the primary care intranet. Patients should be given the npsa booklet see guidance and resources on discharge, nurses should ensure patients know their drug dosage and arrange followup care. National patient safety agency npsa, nhs england and the medicines and healthcare products. This vha directive defines the requirements for the use. Published guidance on this topic 12 new guidance in the last 6 months 1 updated guidance in the last 6 months 0 in development guidance 1 nice advice. The hscb warfarin audit tool see appendix 1 and the audits available as part of computerised decision software systems cdss e. Updated guidelines on outpatient anticoagulation patricia wigle, pharmd. To understand the warfarin patient pathway and how you can contribute to safety as per the npsa safety alert 2. Date of the next inr test and contact numbers for advice should be. There is evidence that anticoagulant dosing software helps to maintain the inr levels within the therapeutic range, extend the time between inr tests and effectively manage anticoagulant records facilitating service audit. Anticoagulant patient safety alert advice for social care. Each patient should be issued with an oral anticoagulation therapy oat.
When avoiding drugs known to interact with a given anticoagulant is not an option, we suggest that warfarin is preferred because dose adjustments based on inr monitoring can facilitate titration of the anticoagulant response. Update prescribing and dispensing software to include methotrexate alerts and prompts. The york health economics consortium model carried out for the west yorkshire cardiac and stroke network gave the following results. Warfarin quality metrics npsa audit report inrstar help. There is evidence that anticoagulant dosing software helps to. Anticoagulation management clinical topic collection gathers the latest guidelines, news, jacc articles, education, meetings and clinical images pertaining to its cardiovascular topical area all in one place for your convenience. Decision support software cdss or by approved clinical guidelines.
In november 2019 the nhs england and nhs improvement national patient safety team began issuing alerts as national patient safety alerts. Warfarin warfarin therapy at 10 mg daily for two days may. People currently taking warfarin who, despite evidence of good compliance with medication and monitoring, have poor anticoagulant control. Dosing practices should use computer dosing software systems. This enhanced service specification for the provision of safe and reliable anticoagulant monitoring outlines the more specialised services to be provided. People not taking warfarin because of allergy or intolerance, or where routine inr monitoring may be impractical monitoring of renal andor liver function is still required. Screening committee guidance and the principles of the npsa safety alert.