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Actions that can make anticoagulant therapy safer: Alert and other information

Reference number
0440
Central Alert System (CAS) reference
NPSA/2007/18
Issue date28 March 2007
Action date (if applicable) (date field)13 March 2008
DH Gateway reference
7734
TypeAlert

This Patient Safety Alert advises healthcare organisations to take steps to manage the risks associated with the prescribing, dispensing and administering of anticoagulants.

 

Anticoagulants are one of the classes of medicines most frequently identified as causing preventable harm and admission to hospital.

 

Healthcare organisations in England and Wales should:

  1. Ensure staff are properly trained.
  2. Review and / or update written procedures and clinical protocols to ensure they reflect safe practice.
  3. Audit anticoagulant services using BSH/NPSA safety indicators as part of the annual medicines management audit programme. 
  4. Ensure that patients prescribed anticoagulants receive appropriate information. 
  5. Promote safe practice for prescribers and pharmacists to check that patients’ blood clotting (International Normalised Ratio, INR) is monitored regularly and that the INR level is safe before issuing or dispensing repeat prescriptions for oral anticoagulants.
  6. Promote safe practice for prescribers co-prescribing one or more clinically significant interacting medicines for patients already on oral anticoagulants: arrange for additional INR blood tests and inform the anticoagulant service that an interacting medicine has been prescribed.
  7. Ensure dental practitioners manage patients on anticoagulants according to evidence-based therapeutic guidelines. 
  8. Amend local policies to standardise the range of anticoagulant products used, incorporating characteristics which promote safer use.
  9. Promote the use of written safe practice procedures for the administration of anticoagulants in social care settings.

 

Resources listed below:

  • Patient Safety Alert
  • Template service audit form
  • Information for community pharmacists, GPs and social care providers
  • Poster for dental practices on how to manage patients who are taking warfarin and undergoing dental treatment
  • British Society of Haemotology Standards for anticoagulants
  • Risk assessment reports

 

See also:

 

 

Although the deadline for actions has passed, this guidance remains best practice. It should be followed to prevent future patient safety incidents.

 

 

Actions that can make anticoagulant therapy safer - Patient Safety Alert
Actions that can make anticoagulant therapy safer - Patient Safety Alert - 294 KB 0440 - Actions that can make anticoagulant therapy safer - Patient Safety Alert - 2007-03-28- V1
Anticoagulant template service audit form
Anticoagulant template service audit form - 194 KB 0440 | Anticoagulant template service audit form | 2007-03 | v1
Anticoagulant therapy: information for community pharmacists
Anticoagulant therapy: information for community pharmacists - 823 KB 0440B - Anticoagulant therapy: information for community pharmacists - 2007 - V1
Anticoagulant therapy: Information for GPs
Anticoagulant therapy: Information for GPs - 313 KB 0440F | Anticoagulant therapy: Information for GPs | 2007-03 | v1
Anticoagulants: advice for social care providers
Anticoagulants: advice for social care providers - 438 KB 0440C - Anticoagulants: advice for social care providers - 2007 - V1
Managing patients taking warfarin and undergoing dental treatment - Poster
Managing patients taking warfarin and undergoing dental treatment - Poster - 182 KB 0233G - Managing patients taking warfarin and undergoing dental treatment - Poster - 2006-01 - V1
Safety indicators for anticoagulant services
Safety indicators for anticoagulant services - 443 KB 0417a | BJH Safety indicators for anticoagulant services | 2007-03 | v1
Oral anticoagulants 3rd edition - 2005 update
Oral anticoagulants 3rd edition - 2005 update - 106 KB 0417a | Oral anticoagulants 3rd edition - 2005 update | 2007-03 | v1
Oral anticoagulants 3rd edition 1998
Oral anticoagulants 3rd edition 1998 - 438 KB 0417a | Oral anticoagulants 3rd edition 1998 | 2007-03 | v1
Guidelines on the use and monitoring or heparin
Guidelines on the use and monitoring or heparin - 159 KB 0440a | Guidelines on the use and monitoring or heparin | 2007-03 | v1
Risk assessment of anticoagulant therapy
Risk assessment of anticoagulant therapy - 266 KB 0233 - Risk assessment of anticoagulant therapy - 2006-01 - V1
Anticoagulants - Risk assessment grid
Anticoagulants - Risk assessment grid - 114 KB 0233H - Anticoagulants - Risk assessment grid - 2006-01 - V1
Anticoagulation Compliance Checklist
Anticoagulation Compliance Checklist - 64 KB Anticoagulation Compliance Checklist, NPSA alert 18