Anticoagulant Safety in Clinical Practice

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n TOC o “1-3” h z u HYPERLINK l “_Toc415330780″Introduction PAGEREF _Toc415330780 h 3

nHYPERLINK l “_Toc415330781″Indications for anticoagulants use PAGEREF _Toc415330781 h 4

nHYPERLINK l “_Toc415330782″Medication errors PAGEREF _Toc415330782 h 5

nHYPERLINK l “_Toc415330783″Anticoagulant safety in clinical practice PAGEREF _Toc415330783 h 6

nHYPERLINK l “_Toc415330784″Anticoagulants Medical Errors PAGEREF _Toc415330784 h 9

nHYPERLINK l “_Toc415330785″Conclusion PAGEREF _Toc415330785 h 14

nHYPERLINK l “_Toc415330786″References PAGEREF _Toc415330786 h 16

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nIntroduction

nAnticoagulants are drugs that are used to prevent and treat blood clots in the blood stream. They play a crucial role in saving life because blood clots block the blood vessels hence preventing continuous flow of blood (Mousa 2004, p. 71). Consequently, blocking of the blood vessels leads to insufficient supply of oxygen in crucial parts of the body such as the lungs, brain and heart. In addition, most of these parts can be damaged which causes problems associated to heart attack and stroke (Turgeon 2004, p. 57). Furthermore, they can lead to serious problems especially when they occur in deep vein thrombosis. Nonetheless, blood clots are important when there is a wound outside the body as they protect the body from excessive loss of blood. After a blood vessel is damaged, the blood produces platelets, which help the body to clump and become sticky around the affected area. The platelets produces clotting factor, which reacts with proteins in the blood. After cascade of chemical reactions, it produces solid protein known as fibrin. The fibrin traps platelets and blood cells that protect against excessive loss of blood (Greer, Arber, Glader, List, Means, Paraskevas, Rodgers and Foerster 2014, p. 62).

nsIn a healthy body, certain chemicals usually destroy a clot that is formed in the blood vessels, which dissolves them. Therefore, the body creates a balance between preventing and forming clots. A clot is usually formed unless a blood vessel is cut or damaged rather than within the bold vessel. Nonetheless, due to several body disorders and illnesses, blood clots are formed within the blood vessel that have not been cut or injured (Greer, Arber, Glader, List, Means, Paraskevas, Rodgers and Foerster 2014, p. 91).

nIn this respect, anticoagulant functions to destroy the chemicals that facilitate formation of clots within the blood vessels. In particular, they interfere with Vitamin K – that contributes to formation of blood clots. Besides, they prolong the formation of fibrin (Kee, Hayes and McCuistion 2012, p. 65).

nWide varieties of anticoagulants are used to prevent formation of clots within the blood vessels. Warfarin is the most commonly prescribed anticoagulant among patients. On the contrary, other types of anticoagulants used include phenindione and acenocoumarol but these drugs are rarely prescribed (Greer, Arber, Glader, List, Means, Paraskevas, Rodgers and Foerster 2014, p. 112). However, they are used in special circumstances, for instance, when a patient is allergic to warfarin. Other types of anticoagulants include heparin.

nIn addition, there are other new oral anticoagulants, which include dabigatran, apixaban and rivaroxaban. Essentially, new oral anticoagulants have many advantages as compared to warfarin. for instance, they have instant action after administration, lower dietary or drug interactions, minimum inter-patient inconsistency (Charney 2012). Besides, new anticoagulants have a wide range of therapeutic window. Most importantly, the drugs are more convenient as compared to warfarin because they can be administered in fixed doses and do not require close monitoring for outpatient (Charney 2012).

nIndications for anticoagulants use

nAnticoagulants are normally prescribed in case a patient is already having a blood clot. The administration of anticoagulants is aimed at preventing the blood clot from becoming bigger in size (Edardes 2008, p. 128). Similarly, persons who are at risk of having a blood clot are prescribed for prevention purposes. For instance, persons with frequent cases of atrial fibrillation are advised to use anticoagulants. Likewise, some cases of blood disorder such as antiphospholipid syndrome require regular prescription of anticoagulants. According to National Patient Safety Agency, people suffering from endocarditis and mitral stenosis are at risk of blood clot formation hence anticoagulation prescription (Edardes 2008, p. 110).

nMedication errors

nMedication errors occur when a failure in the process of treatment causes or is likely to cause harmful effects to a patient. In this respect, these errors occur during the process of prescription, manufacturing, dispensing, administering and drug monitoring (Aronson 2009, p. 3). Prescription errors when a practitioner is writing the prescription, inappropriate prescribing and overprescribing. Dispensing errors occurs due to wrong label, wrong formulation and wrong drug (Wachter 2008, p. 13). A medical professional may cause monitoring error due to erroneous alteration or failing to alter when required. In addition, they influenced by memory lapses, action errors and knowledge errors. Monitoring errors can lead to serious problems if proper measures are not taken into consideration. Furthermore, errors in prescribing are caused by illegibility. Reducing medication errors is very crucial because it assists in balanced prescribing. The latter involves use of a drug that is suitable to the condition of a patient and that offers a balance between harm and benefits. For instance, errors due to missed dose or additional dose contribute to about 12 per cent and 11 per cent (Aronson 2009, p. 4-8)

nThe indications, amount, effect and how anticoagulant drugs functions are various variables that need keen attention during prescription, dispatching, administering to the client and assessing the impacts of the medication. The utilization of these medicines needs extensive strategies by giving out the dosage and monitoring its effects to minimize threats related to its use so that great patient outcomes can be produced (Scully and Cawson 2005). Lack of proper implementation of professional regulations as well as insufficient competencies of health care personnel influence greatly the outcome of these anticlotting drugs (Wachter 2008, p. 80). The manner in which they are prescribed, administered and monitored is also another aspect.

nAnticoagulant safety in clinical practiceMedication errors contribute to huge problem of patients who are hospitalized. Reports indicate that anticoagulant is a major source of these errors. Medical errors in anticoagulant use have been a source of accidental accidents. The amount of anticoagulant is administered to a patient considering its administration, such warfarin (Lee, Lee, Kim, Lee, Choi and Cho 2007, p. 5). Its provision in more than strength has the possibility of adding the potential risks of overdose and therefore needs an additional step of educating the patient particularly in older people. Poor documentation of the reason as well as the treatment plan during the initial stages of anticlotting therapy also plays a role in mistakes that are encountered (Camire, Moyen and Stelfox 2009, p. 91). This will result to poor and insufficient clinical auditing of anticlotting drugs hence leading to errors.

nAdditionally, safety checks that are not sufficient at repeat prescriptions and dispenses that are repeated contributes to the errors committed administration of anticlotting substance therapy. Potential confusion has also been noted that arise from different strength tablets that are normally presented in coded packs that are colourless (Kitchens, Kessler and Konkle 2013, p. 23). The client seeking medical care safety alert offers advice to various institutions dealing with health to ensure that appropriate measures are put in place to control the potential risks that are associated with the prescription and administration of anticlotting substances. These anticlotting substances form one of the categories of drugs that are mostly recognized as resulting to avoidable harm in addition to being admitted in the health facility (Charney 2012, p. 9). Institutions dealing with the provision of health care should therefore ensure that their staffs are properly trained on how to curb these mistakes that frequently takes place within their settings, and should it happen, the necessary action or remedy to take.

nErrors that occur during the process of medication are those mistakes committed unintentionally or events that can be avoided during the process of assigning, giving out, administering or evaluating a medicinal substance and form a major avoidable source of undesired effects in the medical practice. They account for 25 per cent to 30 per cent of the overall mistakes that occurs during the process of medication (Wachter 2008, p. 79). In this regard, many countries such as the US, Australia and the UK have recorded significant cases of anticoagulation medical errors in their hospitals.

nFanikos, Stapinski, Koo, Kucher, Tsilimingras, and Goldhaber (2004) conducted a study in a women hospital aiming to determine incidents of medical errors related to anticoagulant (Fanikos, Stapinski, Koo, Kucher, Tsilimingras, and Goldhaber 2004). The hospital was adequately equipped with safety personnel and advanced computer technology in order to observe and minimize medication errors. The researcher used cases on anticoagulation medication errors from 1999 to 2003. The cases of medication errors occurred during administrations for treatment and during prophylaxis. The cases in the study included thrombin inhibitors such as lepirudin, argatroban, warfarin, low-molecular weight heparin and unfractionated heparin (Fanikos, Stapinski, Koo, Kucher, Tsilimingras, and Goldhaber 2004).

nThe study established that medication errors lead to frequent hospitalization of patients. A study conducted by Scobie, Thomson, Cook and Carthey (2005) indicated that in a period of three years and a half they recorded approximately 130 medication errors related to anticoagulation use. The recorded cases represent approximately 7.2 per cent of all medication errors in the hospital of study. Similarly, the hospital recorded 24 medication errors in every 10 000 patients. In particular, for every 1000 patients who received anticoagulant medication, there were 1.72 errors. Anticoagulant that was used for medication contributed to about 67 per cent of all anticoagulant medication errors (Scobie, Thomson, Cook and Carthey 2005, p. 7).

nTherefore, anticoagulants that were used for prophylaxis caused 33 per cent of the anticoagulation medical errors. In addition, reports indicated that approximately 66 per cent of medical errors were linked to unfractionated heparin while warfarin caused nearly 23 per cent. Besides, about 9 per cent of the cases were caused by heparin of low-molecular weight while lepirudin and gatroban contributed to 2 per cent of the cases (Fanikos, Stapinski, Koo, Kucher, Tsilimingras, and Goldhaber 2004, p. 4). Nonetheless, the study established that the medical errors did not contribute to death of the victims, but they led to hospitalization of about 6.2 per cent of victims who needed medical attentions. Most notably, approximately, 1.5 per cent required prolonged hospitalization (Fanikos, Stapinski, Koo, Kucher, Tsilimingras, and Goldhaber 2004, p. 35).

nAnticoagulants Medical ErrorsFurthermore, the biggest medication errors occurred from use of argatroban and lepirudin with 30.8 cases and 27.8 cases in every 1 000 patients treated. Unfractionated heparin leads to 1.27 events per 1000 treated patients while low-molecular weight heparin lead to 1.18 events in every 1000 treated patients (Scobie, Thomson, Cook and Carthey 2005).

nResearch indicated that approximately 29 per cent of errors were caused by administration of anticoagulant at the wrong frequency or rate. The most common cause was administration of unfractionated heparin at 26.9 per cent. Errors due to missed dose or additional dose to patients during anticoagulant administration contributed to about 12 per cent and 11 per cent respectively (Scobie, Thomson, Cook and Carthey (2005). However, these cases were linked to the use of warfarin. Additionally, the study identified that administering incorrect dose led to 7.7 per cent of the medical errors while wrong time led to 10 per cent of the anticoagulation medical errors (Scobie, Thomson, Cook and Carthey 2005).

nResearch revealed that the majority of anticoagulation medical errors occur during administration of drug. For instance, parenteral and infusion pump delivery system caused 23.1 per cent of the medication errors especially during heparin administration. The medical staffs were involved in errors such as transcription, violation of rules and memory lapses, which include 12.3 per cent, 13.1 per cent and 19.2 per cent of these errors respectively. Meanwhile inadequate knowledge and preparation errors only contributed to the least number of errors, which included 1.5 per cent each (Fanikos, Stapinski, Koo, Kucher, Tsilimingras, and Goldhaber 2004, p. 7).

nTherefore, thrombin inhibitors via direct inhibitors linked to the highest number of anticoagulation medical errors in heparin use. The study identified that 30 patients in 1000 are affected by this problem following their treatment. Heparin administration requires both pump and intravenous delivery couple with constant monitoring (Cousins, and Harris 2006, p. 2). Reports by NPSA indicate that in 2005, there were 311 cases related to anticoagulant medicine in the United Kingdom. In these cases, they contributed to two deaths in that year. Furthermore, between 1990 and 2002, NPSA reported 600 cases of medical errors in the use of anticoagulant. Unfortunately, it recorded 120 death cases resulting from medical errors cases. The cases were caused by negligence that led to harm of the patients. According to NPSA, 77 per cent of the total deaths (92 deaths) were associated to warfarin while 23 per cent (28 deaths) were related to heparin use (Cousins, and Harris 2006, p. 11).

nThe Medical Defence Union in the UK noted 80 deaths out of 223 cases of anticoagulation medical errors. In particular, these deaths were caused by errors in monitoring of insufficient laboratories and drug use. According to the Medical Defence Union, high rate of medical errors from anticoagulant use is caused by negligence. In countries such as Australia and the US, medical errors related to anticoagulation occupy the top five positions in terms of patients’ safety (Cousins, and Harris 2006, p. 11). Most notably, in the UK anticoagulation medical errors are one of the top three in fatal medication incidents. Therefore, the NPSA has prioritized measures to control these medical errors in partnership with the British Society for Haematology. Additionally, in the UK most of the people (nearly 500 000 patients) use warfarin tablets or other anticoagulation tablets (Cousins, and Harris 2006, p. 11).

nReports indicate that in the United States, medication errors in the use of anticoagulants is one of the top five issues incidents related to the safety of patients. Similarly, in the United Kingdom, anticoagulants lead to serious medication errors among different kinds of drugs (Cousins, and Harris 2006, p. 11).

nBetween 1997 and 2007 the Joint Commission’s Sentinel Event Database reported 446 medication errors. Out of these 32 cases (7.2 per cent) involved anticoagulation medical errors. In addition, out of these 32 cases, 75 per cent encompassed use of heparin. Moreover, MEDMARX reported more than 59 300 medication errors associated to anticoagulation in the United States between 2001 and 2006 (Joint Commission 2008, p. 1). Most notably, approximately 3 per cent of these anticoagulation medical errors caused death or harm while about 60 per cent affected the well-being of the patient. The Joint Commission’s Sentinel Event demonstrated that administration errors were the main causes of adverse cases associated to medication of anticoagulants (Joint Commission 2008, p. 9).

nFurthermore, the report indicated that the majority of medication errors are caused by low molecular weight heparin and unfractionated heparin. Most importantly, these are the most commonly used anticoagulants in hospitals. The study also noted that other anticoagulants that cause medication errors include lepirudin and argatroban (Joint Commission 2008, p. 7).

nThe Joint Commission also noted that many factors contribute to anticoagulation medication errors. Inadequate standardization for packaging, labelling and naming of these drugs establishes confusion. The Joint Commission shows that low molecular weight heparin syringes are easily confused by heparin flush syringes (Joint Commission 2008, p. 9). Moreover, in hospital settings they use other anticoagulants such as tinzaparin, dalteparin and enoxaparin that are less commonly known. Consequently, they lead to erroneous dosing and duplication medications. Profession who prescribe these drugs are prone to making errors because of changes in prescription and administration strategies, increase in the list of drugs and assay methods (Joint Commission 2008, p. 7). Besides, a variety of dosing regimens produce a challenge to the professionals who infrequent administer or prescribe drugs.

nSome of the tasks such as individualized or specific monitoring information and instruction regarding drug administration and prescription may fail to be properly communicated or documented in the process of hand-offs or transfers. Most of anticoagulant regimens are designed for older people hence it is difficult to treat paediatric patients such as neonates.

nAnticoagulants are one of the types of drugs that are regularly generating harm to patients due to medical errors. For the safety of a patient, it is important to follow seven steps to patient safety in health practice. When the health professionals such as pharmacists, clinicians and prescribers follow these seven steps, it helps to make anticoagulation therapy safe to the patients. Moreover, it enables to meet contractual needs, accreditation processes and clinical governance standards (National Patient Safety Agency 2004). According to NHS, medical professionals should follow the seven steps. The first step includes building a safety culture, second is supporting and leading practice teams while the third is integrating risk management activity. The fourth step is promoting reporting of information while the fifth is communicating and engaging with the public and patients. The six step demand that medical officers must be committed to share and learn safety lessons. Finally, health care professionals should execute solutions in order to control the harmful effects of anticoagulant use (National Patient Safety Agency 2004).

nDuring adverse effects of anticoagulation therapy, it is important for clinicians to decide on the best methods of monitoring these cases. In particular, they should monitor admissions to secondary care (NICE 2008). The medical practitioners are required to implement the recommendations as stipulated the NICE clinical guideline on the experience of patients. In addition, they should shift their practices in order to satisfy the NICE quality standards according to NHS services. In order to ensure anticoagulant safety, medical professional should ensure that they have the necessary competencies, skills and training. Training ensures that medical professionals offer quality health education to patients on compliance with anticoagulation therapy (NICE 2008).

nReports from the NRLS on medication incidents by therapeutic group indicate that anticoagulant therapy caused four deaths and seven cases of severe harm in the UK. Therefore, the total numbers of safety issues related to anticoagulation in the UK were ten in 2007 (National Patient Safety Agency. 2007). According to NRLS, safety issues related to anticoagulants can be reduced through effective communication. Therefore, anticoagulant clinic, staffs and patients need to establish effective communication in order to reduce these cases. Moreover, effective monitoring system should be implemented, especially during anticoagulant therapy (National Patient Safety Agency 2004). As reported by NRLS, death cases occur when intra-arterial and intravenous heparin are not administered or delayed in emergency cases (Bhalla, Howe, and Baglin 2009).

nFurthermore, dosing instructions for patients makes a patient suffering from pulmonary embolism and deep vein thrombosis to miss anticoagulation medication leading to severe harm (National Patient Safety Agency 2007). In such cases, NPSA recommends that patients should be provided with necessary written and verbal communication in order to make it safer. In addition, medical institutions should review and/or update clinical protocols and procedures related to anticoagulant therapy (Bhalla, Howe, and Baglin 2009). Furthermore, NPSA recommends that promotion of safe practices is crucial amongst pharmacists and prescribers to monitor the blood-clotting pattern among pharmacists and prescribers as well as co-prescribers. Local policies should be amended to standardize the variety of anticoagulants products utilized in hospitals. Besides, care homes should utilize written procedures for safe practice of anticoagulants. (NPSA 2010)

nConclusionAvoiding mistakes during medication needs vigilance and advanced technology in a right manner to ensure that right guidelines are adhered to (Aronson, 2009, p. 7). Physicians’ orders via computers minimizes mistakes by pin-pointing and informing physicians to patients interaction of drugs, hence removing prescriptions that are written in a poor way, and helping give support via decisions on dosing regiments that are up to the standards. There is also the need to utilize practices that are safe which are found in a health institution by health personnel. This also calls for elimination of distractions when preparing and formulating medications for a patient (Lewis, Heitkemper and Dirksen 2004). Finally, it is also important to single out the role of fatigue in enhancing mistakes during medications.

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