Storyboard Submission NHS Wales Awards Title Improving Patient Safety How ABHB Ward Pharmacists Monitor Elevated INRs

Transcription

1 Storyboard Submission 1. Title Improving Patient Safety How ABHB Ward Pharmacists Monitor Elevated 2. Brief Outline of Context As part of the 1000 Lives Plus initiative, ward pharmacists throughout ABHB started investigating patients with an elevated international normalised ratio (INR >5.0). Pharmacy receives a daily from pathology detailing all in-patients whose INR is >5.0, prompting follow up by ward pharmacists. This initiative involved devising a checklist to investigate why a patient s INR has become elevated. The ward pharmacist then ensures the patient is managed appropriately (i.e. the dose has been withheld / reduced, the INR closely monitored, or the effects of warfarin reversed). Implementation of these measures has improved patient safety. It has reduced patient risk and decreased the chances of the INR becoming further elevated, which can result in haemorrhage. 3. Brief Outline of Problem The anticoagulant warfarin has a narrow therapeutic index and is classed as a high risk medicine. taking warfarin need regular monitoring of their blood to ensure the dose is safe and thus prevents adverse events. The National Patient Safety Association issued guidance relating to anticoagulants (NPSA/2007/18) 1 requiring implementation across all Health Boards. ABHB pharmacy met with the audit department to review the number of patients with INR >5.0 & >8.0 to discuss preventative measures. Pharmacists started recording information on elevated and investigated why the INR had become raised. To ensure the NPSA criteria were met, pharmacy audited current practice within RGH. These results were fedback to the thrombosis committee and any recommendations regarding monitoring of the INR by pharmacists were adapted into departmental polices. 4. Assessment of Problem and Analysis of its Causes During review with the audit department the number of elevated proved unpredictable. As the number of patients taking warfarin within ABHB hospitals varies on a day to day basis. Due to the potentially high numbers a pro-active management approach was taken. To assist, the Consultant Haematologist presented to pharmacy staff on causes of elevated INR and warfarin management. Meanwhile an All Wales project lead to the development of the All Wales Anticoagulant Chart, enabling the consistent use of a single warfarin chart by junior doctors across Welsh hospitals. Pharmacy produced a newsletter to introduce the new chart and also audited its use. 1

2 The form used to record an elevated INR was adapted to ensure the patient was being managed appropriately. that had been inappropriately managed were flagged to the team. For hospital in-patients an electronic Datix error form was and for patients admitted to hospital with a high INR this has been fedback to the GP practice. A monthly report is were the are totalled and learning points fedback to pharmacists. The report is discussed at the Thrombosis Committee meeting. One common factor for an elevated INR has been the of interacting antibiotics. This information has been sent out as a newsletter to feedback to prescribers. 5. Strategy for Change The form being used for monitoring has changed to ensure relevant information could be extracted and to identify themes. If a patient has been inappropriately managed this is now reported to the Consultant on a Datix form. The process now involves better feedback to Primary. An ABHB primary care pharmacist was involved to look at how could be managed by community pharmacists and GP practices and produced a document on lessons learnt. Pharmacy met with pathology to look at how bloods are monitored within the anticoagulant service and the information given to patients/gp practice regarding monitoring of INR and interacting medicines. Pharmacists are now more aware of how to manage an elevated INR, what the contributing factors are and how trying to predict this can stop the INR becoming high. Originally this was discussed monthly at the Safer Patient Initiative Group. Now results are presented to the Thrombosis Committee for feedback on how this could be improved. 6. Measurement of Improvement Daily >5.0 have been audited to see if there has been a reduction in numbers. Due to variability between patients this has not been the case. However the number of inappropriately managed has reduced. This system also ensures that something is done when the INR becomes elevated to try and stop a further increase and subject the patient to harm. 7. Effects of Changes This change has improved patient care and is in line with the original NPSA guidance. Pharmacy policies involving warfarin have been collated to ensure patients are monitored throughout their in-patient stay (i.e. their INR recorded on discharge and the patient referred to anticoagulant clinic). 2

3 This work is continually being developed and now has a link with Primary and discussion with GP practices if a patient has not been monitored, or dosed appropriately. If the computer dosage system DAWN has made an error this is recorded. Resulting in improved communication with the anticoagulant clinic. The main change is that patients are being managed appropriately with the guidance of a pharmacist when INR >5.0. This means pharmacists are actively involved with preventing further harm or an adverse event. 8. Lessons Learnt Although this initiative was taken forward by pharmacy it has shown that if changes are needed to imporve patient care all disciplines of health care professionals (HCPs) must be involved. It has also shown the importance of feedback of inappropriate management is important to improve practice. 9. Message to s When a patient is on a high risk drug such as warfarin everyone involved in patient care should be cautious. All HCPs should have an understanding of what can happen if an INR becomes too high and how this should be managed. At ward level, nurse, doctors and pharmacists should be responsible for checking an INR before giving a dose. Within primary care, patients need to inform doctors/nurses/pharmacists that they take warfarin and should be closely monitored. References 1. Anon. Actions that can make anticoagulant therapy safer Patient Safety Alert 18. National Patient Safety Agency March Cousins D, Harris W. Risk assessment of anticoagulant therapy. National Patient Safety Agency January Anon lives campaign - Prevent Harm from High Alert Medication- Anticoagulants in Primary Presentation. 3

4 INR s over 5 - RGH Primary Jan Feb March April May June July Dexamethasone (2), Ibuprofen, transvasin Aug , (2), Amiodarone,, Ibuprofen gel (on ward) 0 4

5 2011 Sep Amiodarone Oct Amiodarone (3) Nov (2) Ibuprofen Simvastatin Dec Naproxen Primary

6 INR s over 5 - RGH Jan (3) (3) Co-codamol Feb (4) Dexamethasone Amiodarone Citalopram March (2) April May Carbimazole Primary June (2) 6

7 (2) Citalopram 2012 July Primary Aug Sep Ibuprofen (2) Oct Nov (2) Dec (3)