Warfarin prescription and administration: reducing the delay, improving the safety

Area of Science:

• Pharmacology and Therapeutics
• Patient Safety and Quality Improvement

Background:

• Warfarin administration in hospitals is prone to errors due to its narrow therapeutic index and need for regular INR monitoring.
• NICE and Bristol Royal Infirmary guidelines recommend fixed daily dosing (14:00) for warfarin to ensure standardization and prevent patient harm.
• Current practices often result in delayed or inconsistent warfarin administration, particularly during minimal staffing hours.

Purpose of the Study:

• To reduce adverse outcomes linked to warfarin prescription and administration errors.
• To improve the timeliness of warfarin dosing, aiming for administration within an hour of the 14:00 prescription.
• To decrease the proportion of International Normalized Ratio (INR) results falling outside the patient's target range.

Main Methods:

• A quality improvement project was conducted across seven acute medical wards using the Model for Improvement.
• Intervention involved introducing a 'warfarin box' system to standardize and facilitate timely administration.
• Key metrics tracked included the percentage of warfarin doses administered within one hour of 14:00 and the proportion of INR results outside the target range.

Main Results:

• Baseline data revealed only 24% of warfarin doses were administered within an hour of 14:00, with 64% given after 17:00.
• Post-intervention, warfarin administration within an hour of 14:00 increased to 49%.
• This improvement in timely administration correlated with a significant reduction in INRs above the target range, decreasing from 23% to 9%.

Conclusions:

• The implementation of a standardized warfarin dosing system, such as the 'warfarin box', effectively improved medication administration timeliness.
• Standardized warfarin administration is associated with a reduction in critical INR monitoring parameters, suggesting enhanced patient safety.
• This quality improvement initiative demonstrates a successful strategy for mitigating warfarin-related errors in a hospital setting.