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Reducing Anticoagulant Related Adverse Events: Improving Hospital Safety Infrastructures and the Impact of Pharmacist Anticoagulation Services

Heath R. Jennings, Pharm.D., BCPS, Stacy Voils, Pharm.D., BCPS, Kevin Poe, Pharm.D., BCPS, Marla Whitaker, Pharm.D., Eric Miller, Pharm.D., Kelly Watson, M.D., Anthony Morano, M.D.


Saint Joseph HealthCare, Lexington, Kentucky

This interdisciplinary project was conducted to reduce the incidence of harmful anticoagulant-related ADE and to evaluate the impact of clinical pharmacist involvement with patient centered anticoagulation therapy. 

A three-month drug use evaluation (DUE) established baseline utilization practices.  Baseline rates of harmful ADE and medication errors were evaluated by retrospective chart review.  A formal gap analysis of anticoagulant medication use provided comparison to national practices and initial targets for improvement.  Failure Modes and Effects Analysis was utilized as a structured, data-driven approach for predicting and eliminating defects in the three principal processes of anticoagulant use – prescribing, dispensing, and administration.  Medication safety systems were created and modified throughout this project.  Most notably, a clinical pharmacist managed anticoagulant therapy consult service was established.  A six-month follow up DUE provided prospective comparisons between physician and pharmacist anticoagulation management practices.  Primary outcomes included occurrence of major and minor bleeding reactions, incidence of thrombosis, and length of stay among the groups.  Descriptive statistics were used to evaluate patient demographics and multivariate analysis was employed to compare patient outcomes.  Economic analysis evaluated hospital resource input costs and the cost-benefit ratio for the pharmacist managed anticoagulant services.

During this project, the team tracked and evaluated 15,062 patient days of anticoagulant therapy (n=1,222 patients).  A target 50% reduction in baseline risk of medication error occurrence was surpassed by the observed 88% risk reduction.  Anticoagulant related ADE were reduced by 50% after three months and by >90% after an additional six months.  ADE incidence was reduced from 14.75% to 0.07% and overall hospital-wide medication safety system reliability increased from 2.55 to 4.69 standard deviations.  Six hundred twenty nine and 424 physician managed patients were evaluated during the DUE in 2004 and 2006 respectively.  A total of 103 patients were managed by pharmacists in 2006.  From 2004 to 2006, improvements in physician prescribing and management of anticoagulants were observed.  Better anticoagulation outcomes were observed among patients managed by pharmacists versus physicians: percent of patients with an INR > 4.0 (6.8% versus 24.5%, respectively); major and minor bleeding events (0.0% versus 6.4% and 1.0% versus 4.5%, respectively); and length of stay (2.6 versus 6.7 ± 4.3 days, respectively).  Pharmacist managed anticoagulation services were associated with significant reductions in bleeding risk (OR 0.09; 95% confidence interval {CI} 0.01-0.6) and shortened length of stay (OR 0.4; CI 0.2-0.8).  Cost-benefit ratio for pharmacist anticoagulation services was 1 to 11.2 or a return of $11.20 for every $1 invested in the program.  Overall financial impact of the consult service was $150,380 for the six months evaluated (n=103 patients) and $300,760 annualized at the current consult rate (11% of all possible patients).  The annual impact, when appropriately spread, is estimated to exceed $1.5 million.

Utilization of a quantitative data-driven strategy to reduce anticoagulant adverse events effectively improves patient safety and reduces variability in medication use.  A clinical pharmacist managed anticoagulant service significantly improves patient care by reducing anticoagulant ADE and hospital length of stay.

View a pdf of the poster from the Midyear Meeting (573KB).