Managing anticoagulation therapy

Claims that involve the management of anticoagulant medications occur frequently at TMLT, as illustrated in these case studies: “Failure to properly manage warfarin dose”; “Failure to monitor warfarin levels”; “Failure to monitor patient’s postoperative INR”; and “Medication error: Incorrect dose of warfarin” in the Reporter.

Managing the risks associated with anticoagulation therapy falls in the hands of physicians across all specialties. Proper management can reduce the chance of patients being harmed. When prescribing and/or maintaining these high-risk medications, consider the following.

• When delegating any portion of the anticoagulation monitoring process to a staff member, ensure competencies are up to date and documented.
   
• Review current medications — including supplements — at every patient encounter to ensure patients are taking the correct dosage and not experiencing side effects or drug interactions that would require adjustments.
   
• When a patient is on long-term anticoagulation therapy and changes in health status or life situation occur, frequent monitoring can help avoid problems. Significant changes can include hospital or nursing home admission, surgery, or changes in diet.
   
• Medication reconciliation should occur upon hospital admission and discharge to reduce the chances of duplications, omissions, or incorrect dosages.
   
• Written and oral instructions should be provided to the patients and/or caregivers at the initiation of therapy and along the continuum of care. It is important that this education be in simple terms. It should include the risks and benefits of the medication.
   
• Keep the lines of communication open between all health care professionals involved in the care of the patient. Document any discussions or written communication.
   
• Problems can occur when a patient is admitted to the hospital or is scheduled for surgery. Determining and documenting who will manage the anticoagulation while the patient is in the hospital and who will resume the management after discharge can help avoid misunderstandings of who is in charge of that therapy at any given time.
   
• Have written protocols in place outlining:
  • How often to monitor therapy and adjust dosages, including identification of critical values (both high and low) and when physician notification is required.
     
  • How to document the test results and treatment plan
     
  • How to handle patient non-compliance

Even when all of these items are in place or are conducted, patients may still experience an adverse event related to anticoagulation therapy. Documenting the safe practice protocols and all of the care provided by you and your staff is helpful in increasing the defensibility of a claim surrounding this high-risk class of medication.