Policy responses and statements

Name of organisation:

National Patient Safety Agency

Name of policy document:

Improving the Safe Use of Anticoagulant Therapy

Deadline for response:

31 March 2006

Background: Anticoagulants are one of the classes of medicines most commonly associated with fatal medication errors. Since 1990, there have been reports of 120 deaths and many injuries that could have been prevented with safer systems.

The National Patient Safety Agency is undertaking a wide stakeholder consultation on recommendations intended to improve the safe use of anticoagulant therapy. The NPSA plans to issue final recommendations to improve the safe use of anticoagulants therapy to the NHS in England and Wales later in 2006. Comments and suggestions concerning this draft were requested.

COMMENTS ON
NATIONAL PATIENT SAFETY AGENCY
PATIENT SAFETY ALERT

Improving The Safe Use Of Anticoagulant Therapy

Wide Stake Holder Consultation – Response Form

Please send complete form to anticoagulants@npsa.nhs.uk

Your contact details

Organisation Name: Royal College of Physicians of Edinburgh

Contact Name: Lesley Lockhart

Position: Team Leader, Fellowship Support Unit

Telephone: 0131-247 3608 Email: l.lockhart@rcpe.ac.uk

ROYAL COLLEGE OF PHYSICIANS OF EDINBURGH’S GENERAL COMMENTS:

The document is welcomed for addressing a problem that is emerging as a result of the more widespread acceptance of the indications for anti-coagulant therapy and the development of nurse prescribing. The recommendations are clear, achievable and should achieve the reduction of identified risks without excessive cost implications. Access to the websites quoted is not always easy and requires registration.

1. Have the NPSA identified all high risks concerning the use of anticoagulants? Are there additional risks that should be considered? Do you disagree with any of the identified risks?

   The identified risks are all recognised. Additional risks could include communication problems between Secondary and Primary care, and recognition that fixed dose devices are not confined to care homes.

2. Are the recommendations concerning the training and work competences clear and actionable? Are the work competences available on www.saferhealthcare.org.uk sufficiently comprehensive and do they accurately describe the competences required for safe and effective use?

   The six work competencies cover the skills required to supervise anti-coagulation. It is to be assumed that the decision to treat with anti-coagulants remains the responsibility of the GP or hospital consultant. The web-site quoted could not be accessed without registration.

3. Is the use of safe practice indicators a worthwhile method to identify areas of local practice that require improvement, and an effective method for NHS organisations to track improvements to the system?

   Audit of service should be an integral component of these developments. The safe practice indicators should be simple to collect if audit is to be feasible.

4. Is the proposed new two part patient held anticoagulant record supported? Is the recommendation that written confirmation of dose changes practical? Can the patient held information be maintained during a hospital inpatient episode? Can healthcare organisations easily develop patient held information from these templates to meet local needs?

   It is not clear how the two-part record differs in practice from the old record. Patient information is obviously important, but the record should also contain clinical information on the indication for anti-coagulation and the intended duration of treatment. Continuation of the record during episodes of in-patient care is not likely to succeed, frequently patients do not bring drug records into hospital, dosage adjustments in the face of disease may be frequent. It would be more realistic to insist on discharge dosage and reasons for change to be recorded. Written confirmation of dose changes is certainly important.

5. Is there any reason why prescribers and dispensers cannot check that it is safe to issue repeat prescriptions and supplies of anticoagulants before doing so?

   Practices should consider the repeat prescription of Warfarin separately from general repeat prescriptions.

6. Are recommendations for dental practitioners managing patients on anticoagulants supported? Are the draft guidelines clear, evidence based and easily implemented?

   There is certainly a need for clear guidelines to help dental practitioners.

7. Are the proposed standardised methods of supply for warfarin and sodium heparin infusions supported and actionable?

   Standardised supply of Warfarin is supported. There are situations where a concentrated heparin solution may be required, for example, in locking indwelling venous lines for dialysis. However, the great majority of heparin infusions would be simplified by a made-up solution.

8. Are recommendations concerning the safe practice with anticoagulants in care home i.e. written confirmation of anticoagulant dose changes, not packaging anticoagulants in monitored dosage systems, appropriate and implementable?

   The safe practice of not packaging warfarin in monitored dosage systems in care homes is supported and, indeed, it is felt that this should be extended to all patients on dosage systems, whether in a care home or not.

9. Do you have any other comments concerning the draft NPSA Safer Practice Alert ?

   Audit, monitoring and safety would all be facilitated by developing electronic records linked to laboratory computer systems.