![]() A system designed to consider conflicting medications and comorbidities that influence warfarin might be able to recommend specific doses. ![]() An alert triggered by the association of warfarin with an INR that exceeds a certain value (e.g., greater than 3.5) and supported by a management algorithm might have prevented the error that occurred in this case. Requiring morning administration could prevent errors since more staff members (including the primary team responsible for a patient's care) are in the hospital at this time and available to clarify orders.Īlthough not widespread, many hospitals have implemented CPOE with clinical decision support to aid in the dosing and management of warfarin. Lastly, warfarin is traditionally dosed in the evening. Such a policy could have helped prevent the error in this case. For high-risk drugs like warfarin, another policy that potentially could reduce errors would mandate a specific order when the intent is to discontinue or withhold a dose (as opposed to when the intention is to give the medication). A similar policy was in place at the admitting hospital in the case described, but it clearly did not prevent the error. One example is a policy that eliminates standing orders for warfarin and requires the order to be rewritten each day as a one-time order. Many hospitals have implemented institutional warfarin dosing policies that require the medication to be prescribed and dispensed in a specifically described manner. An example of a warfarin dosing guideline is shown in the Table. Proper and safe dosing requires the provider to refer to the guidelines and subsequently use them appropriately. Although distributing evidence-based guidelines for anticoagulant medication administration resulted in a trend toward a decrease in anticoagulant-associated adverse events in one study ( 2), these interventions are generally unsuccessful, as they are only advisory in nature and require no action on the part of the provider. The CommentaryĪnticoagulant drugs are among the most common agents responsible for adverse events in hospitalized patients as well as a frequent cause of medication errors.( 1) Warfarin, in particular, can be quite dangerous-the narrow therapeutic index and its variable pharmacologic response require careful dosing and management.Įfforts to improve the quality and safety of warfarin administration include publishing standardized guidelines, enforcing institutional dosing policies, and using computerized physician order entry (CPOE) with clinical decision support. The patient had a minor nosebleed but no other adverse consequences. Oral vitamin K was given to counteract the effects of the warfarin. The next day, the patient's INR was 5.6 3 days later, it peaked at 7.7. The pharmacy dispensed the medication, and the patient received 15 mg of warfarin. Without checking the progress notes or the patient's INR level for the day, the cross-covering intern gave the nurse a verbal order to give the patient one dose of warfarin, 15 mg. As it turns out, the primary intern had not updated the written signout that day, and warfarin was still listed as an active medication. Having not received a verbal signout from the primary intern, the cross-covering intern reviewed the written signout on the patient and noted that warfarin was listed as one of the patient's medications. Without checking the progress notes or the laboratory values for that day, she paged the night float intern (not the primary intern caring for the patient) who was cross-covering. She was puzzled, as she distinctly remembered from signout that the patient was on warfarin for the prosthetic aortic valve. The intern did not write the order for warfarin for hospital day two and clearly outlined in the daily progress note that the warfarin was to be held.Īfter the shift change, the evening nurse noted that the daily warfarin order had not been written. On hospital day two, the patient's INR had risen to 3.6. The intern caring for the patient ordered her usual outpatient dose of 15 mg x 1. At the admitting hospital, a formal policy required that all inpatient orders for warfarin be rewritten each day to prevent overdosing. On admission, her hemoglobin level was normal and her INR was 2.6. ![]() She had already undergone multiple surgeries, including aortic valve replacement for which she was on warfarin with a goal international normalized ratio (INR) level of 2.0–3.0. A 27-year-old woman with a history of congenital heart disease was admitted for cardiac transplantation evaluation.
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