Reducing anticoagulant medication adverse vents and avoidable patient harm.

Area of Science:

• Healthcare Management
• Patient Safety
• Pharmacology

Background:

• Anticoagulant therapy is standard care, but carries risks of bleeding and thrombotic complications.
• Preventing adverse drug events from anticoagulation was a key process improvement goal.

Purpose of the Study:

• To evaluate the impact of a new anticoagulant management strategy on patient outcomes and safety.
• To assess the effectiveness of a pharmacist-driven intervention in reducing anticoagulant-related adverse events.

Main Methods:

• Established an interdisciplinary team to review anticoagulant practices.
• Implemented a pharmacist-managed anticoagulant therapy service, including consults for initiation, management, and monitoring.
• Utilized collaborative physician and pharmacist practice models.

Main Results:

• Thrombotic events decreased from 4.6% (2004) to 0.0% with collaborative management.
• Hospital-wide bleeding and thrombotic reactions reduced from 11.52 to 0.07 events per 1,000 doses.
• Annual cost savings of up to $9.8 million were identified.

Conclusions:

• Integrated anticoagulant safety across the institution through interdisciplinary collaboration.
• Successfully employed multiple medication safety systems to enhance patient care.
• Demonstrated the value of pharmacist involvement in optimizing anticoagulant therapy.