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Reducing Anticoagulant Medication Adverse Events and Avoidable Patient Harm

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Background: The conventional standard of care for many patients at Saint Joseph HealthCare, a three-hospital system in Kentucky, includes the use of anticoagulant therapy. In view of the morbidity and mortality associated with anticoagulation-related complications, the prevention of bleeding and thrombotic adverse drug events was identified as a primary process improvement initiative.

Methods: Following establishment of an interdisciplinary team, formal evaluations of anticoagulant-use practices and associated patient outcomes occurred via several mechanisms. A variety of process improvement activities were conducted, including the creation of a pharmacist-managed hospital anticoagulant therapy service. A pharmacist consult service for the medical staff provided initiation, management, and monitoring of anticoagulation, including bridge therapy and reversal if necessary.

Results: The rate of thrombotic events decreased from 4.6% in 2004 to 3.9% in 2006 and further decreased to 0.0% for patients managed by collaborative physician and pharmacist practice. Hospitalwide bleeding and thrombotic reactions decreased from a monthly average of 11.52 events per 1,000 anticoagulant doses dispensed in 2004 to 0.07 in 2006. A cost-benefit evaluation indicated an annual savings of up to $9.8 million in avoidable costs.

Discussion: In this interdisciplinary project, anticoagulant safety was integrated throughout the institution, and a variety of medication safety systems were successfully employed.

Document Type: Research Article

Publication date: April 1, 2008

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  • 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.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

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