Reduction in Anticoagulation-Related Adverse Drug Events Using a Trigger-Based Methodology

Authors: Lederer, Jim; Best, Diana

Source: Joint Commission Journal on Quality and Patient Safety, Volume 31, Number 6, June 2005 , pp. 313-318(6)

Publisher: Joint Commission Resources

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Background: An initiative was undertaken by Novant Health System to address warfarin-related adverse drug events (ADEs) using lab-based patient-specific International Normalized Ratio (INR) triggers and pharmacy-based patient-specific Vitamin K triggers. The goal was to reduce ADEs related to the use of warfarin in both the inpatient and outpatient settings. Process improvements and medication management protocols were developed for patients managed with warfarin anticoagulation.

Methods: During each month's seven-day sampling period, the hospital information system generated the lab and pharmacy triggers, and the clinical pharmacists used these patient-specific triggers to identify the patient charts for review. All triggered charts were reviewed. Preliminary harm classification based on the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index was assigned by the clinical pharmacists and recorded for each patient.

Results: The system achieved reductions in ADEs related to warfarin administration on an inpatient management (45%) and outpatient management (52%) basis.

Discussion: Although based on inpatient facility generated triggers, the initiative also served as a reasonable outpatient model, with improvements seen in the outpatient physician intervention groups.

Document Type: Research Article

Publication date: June 1, 2005

More about this publication?
  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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