Introduction and Scope This resource is one of a series produced by the clinical team of the East and South East England Specialist Pharmacy Services. The series aims to support NHS organisations and practitioners from all sectors of care in implementing medication-related requirements published by the NPSA. Many of the items cited in the resource are a collation of information provided by colleagues who have implemented the NPSA publications. This resource provides information on the implementation of NPSA number 18: Actions that can make anticoagulant therapy safer; and this version has been updated so that the associated NPSA documents are listed in Appendix 2 together with links to the documents on the NELM website. The resource will be routinely updated to incorporate new information. If you have any comments or examples of implementation that you would like to share as a part of a future update, please send these to [email protected].
Search strategy This resource was compiled using
Information available via the NPSA web-site: www.npsa.nhs.uk or the NHS Evidence website: https://www.evidence.nhs.uk/nhs-evidence-content/medicines-information
Information from other known web-based sources NHS Evidence (https://www.evidence.nhs.uk/nhs-evidence-content/medicines-information ),
National Prescribing Centre (www.npc.co.uk ) and NPCi (www.npci.org.uk ), East and South East Specialist Pharmacy Services http://www.medicinesresources.nhs.uk/en/Communities/NHS/SPS-E-and-SE-England/, UK Clinical Pharmacy Association (www.ukcpa.org.uk ) and RPSGB: www.rpsgb.org.uk including a search of articles published in the Pharmaceutical Journal www.pjonline.com 2005-2009
Collation of feedback from specific requests to acute trusts and PCTs across London, East and South East England Review of pre-registration audits completed across London, East and South East England 2006-2009 accessed via regional pharmacy education and
How to use this resource to implement NPSA alert number 18: Actions that can make anticoagulant (AC) therapy safer
NPSA alert number 18: Actions that can make anticoagulant therapy safer and supporting documents can be found by looking on the NPSA website at http://www.nrls.npsa.nhs.uk. A summary of the content of the NPSA alert is given Appendix 1 and all the documents are listed in Appendix 2 with links to them on NeLM. The resource summarises the NPSA Actions with information on how different organisations have implemented that particular action. The information to support implementation is divided into these sections as per the NPSA alert and each section is sub-divided into information from mental health, primary care and secondary care organisations : 1. Ensure all staff caring for patients on anticoagulant therapy have the necessary work competencies. 2. Review and update procedures and protocols to ensure they reflect safe practice and that staff are trained to implement them. 3. Audit anticoagulant services using BSH/NPSA safety indicators as part of the annual medicines management audit programme. 4. Ensure patients receive appropriate verbal and written information especially on initiation of anticoagulation and hospital discharge. 5. Promote safe practice with prescribers and pharmacists to check that patients’ INR is being monitored regularly and that the INR level is safe before
issuing or dispensing prescriptions. 6. Promote safe practice for prescribers co-prescribing one or more clinically significant interacting medicines. 7. Ensure dental practitioners manage patients according to evidence based medicine 8. Amend procedures to standardise the range of anticoagulant products used 9. Promote the use of safe practice procedures for the administration of anticoagulants in social care settings The references and examples are numbered to allow cross referencing where resources may provide information that covers more than one of the sections above. Disclaimer: Web-site addresses given in this document were correct at time of writing. If you find the links no longer work, we suggest you attempt accessing the Home page of the site and searching from there. Although the contents have been examined for relevance, inclusion of a reference or its source does not necessarily guarantee the quality and accuracy of its content. Users of this resource will need to satisfy themselves that use of the reference is appropriate for their purposes
Acknowledgements This resource would not have been possible without the contributions from NHS pharmacy teams across the geography covered by the East and South East Specialist Pharmacy Services. We would like to express our thanks to those that have kindly agreed to share their work with us. We would especially like to thank the regional pre-registration pharmacist training centres and the UKCPA administration team for giving us access to information on audits and abstract publications
1P.1.1 NHS Surrey Contains NPSA workforce competencies for prescribing, dispensing and administration in Appendix 2 and in Appendix 6 covers training requirments and gives details of training and annual update training provided by PCT.
1S.1.1 Queen Victoria Hospital NHS Foundation Trust (Provides specialist reconstructive surgery)
In the section entitled training and awareness the issue of prescribers/pharmacists competencies is addressed by requiring them, wihin 2 weeks of joining the trust to provide evidence of having completed specified two BMJ elearning modules. Evidence to be submitted to lead clinician or clinical director. Training requirements for nurses are also specified.
Action plan contains recommendation for doctors to undertake elearning BMJ package or eLfH. For pharmacists CPPE or eLfH. Nurses to be accredited on competency package.
2M.3.2 AC prescription chart to be faxed to GP when patient discharged.
Presc NPSA 18 AC Surrey Mar10
2M.4.1 Sussex Partnership NHS Foundation Trust
Guidelines on prescribing warfarin, split into sections on admission, hospital stay and discharge. Recommends anticoagulant prescription is faxed to GP within 24 hours discharge.
Includes appendices - AC duration and target INRs, summary of food, herbal and drug interactions.
Organisation Details Where to find it Who to contact
2M.4.2 Sussex Partnership NHS Foundation Trust
Page 7 of a regular newsletter alerts trust staff of the guidelines and requirements when a patient is admitted or initiatd on AC.
Newsletter NPSA 18 AC Sussex Partnership Dec 09
2M.4.3 Pink AC prescription chart to be faxed to GP within 24 hours of discharge.
Presc NPSA 18 AC Sussex Partnership Jul 08
2P Primary Care Trusts
2P.1.1 Bedfordshire Community Health Services
Covers prescription for inpatients & outpatients, action if interacting drug is stopped or started, INR monitoring and administration of AC, discharge of patients. It advises against the use of monitored dosage systems unless risk assessment is carried out by community pharmacist.
Organisation Details Where to find it Who to contact
2S Secondary Care
2S.1.1 Barking, Havering & Redbridge University Hospitals NHS Trust
Detailed Administration & Management of AC policy. Includes dosing regimens for initiation (non Fennerty), out of range algorithms, administration protocols, bridging therapy, discharge procedures, counsellling record. Also standards for doctors and pharmacists,.
Comprehensive action plan. Recommends patients monitored by hospital OP clinic, present yellow book each time requesting warfarin repeat prescription as proof of monitoring.
Organisation Details Where to find it Who to contact
2S.4.1 cont’d
Heatherwood & Wexham Park NHS Foundation Trust
Inpatients at Wexham Park Hosp are dosed by members of the AC team. Two new posts were created to ensure inpatients were dosed and discharged safely as required by NPSA 18. This is protocol they use.
Includes discharge checklist and transfer form directly to primary care clinic if suitable.
Includes responsibilities for drs and thrombosis team practitioners.
Inpatient protocol NPSA 18 AC Wexham Mar 10
2S.4.2 Presentation given to clinicians at launch of in-patient dosing service.
Organisation Details Where to find it Who to contact
2S.6.3 cont’d
Luton & Dunstable Hospital NHS Foundation Trust
This dispensing procedure ties in with 2S.6.1 for pharmacy staff.
Disp proc NPSA 18 AC Luton Nov 09
2S.6.4 Labels for front of drug chart to alert all staff patient on warfarin with details to be completed to promote seamless care.
Pres labels NPSA 18 AC Luton Mar10
2S.6.5 Checklist for nursing staff to follow, to be attached by dispensary to TTA bags containing warfarin.
TTA bag Checklist NPSA 18 AC Luton Mar10
2S.7.1 Queen Victoria Hospital NHS Foundation Trust (Provides specialist reconstructive surgery)
Comprehensive policy: If interacting drugs are prescribed the doctor is responsible for checking INR & in outpatient setting for telling patient to have INR checked in 4-7days and informing their AC clinic of the interacting drug.
Appendix 2 is an SOP for nurses to administer, counselling and actions to be taken to ensure safe AC for inpatients and at discharge by pharmacists.
Combined pilot inpatient oral /parenteral AC drugchart which includes referral form to anticoagulant clinic. Page 4 contains checklists for prescribers, nurses and pharmacists and safe transfer of monitoring checks to be signed.
Presc p1 NPSA 18 AC StGeorges Jan10 Presc p2 NPSA 18 AC StGeorges Jan10 Presc p3 NPSA 18 AC StGeorges Jan10 Presc p4 NPSA 18 AC St Georges Mar10
Organisation Details Where to find it Who to contact
2S.9.2 University College London Hospitals NHS NHS Foundation Trust
Discharge checklist which is now incorporated into the inpatient drug chart to be completed by pharmacists.
Discharge checks NPSA 18 AC UCLHNov 09
2S.9.3 IV heparin nomogram and admininstration record.
UFH dosing NPSA 18 AC UCLH Feb 08
2S.9.4 Outpatient AC clinic referal form. States responsibility for monitoring rests with referrer until first appointment. Also asks if patient is recieving LMWH injections when referred.
OP clinic referral form NPSA 18 AC UCLH Sep 09
2S.9.5 Which patients to refer to accredited GP clinics providing a locally enhanced service and how. Written from a secondary care perspective.
Referring to GP clinics NPSA 18 AC UCLH Jul 09
2S.10.1 Western Sussex Hospitals NHS Trust
Action plan which contains recommendation for doctors to undertake e learning BMJ package or e LfH. For pharmacists CPPE or eLfH. Nurses to be accredited on competency package.
3P.2.2 Easy to administer patient questionnarie which could be used in many settings.
Questionnaire NPSA 18 AC TH pct Mar10
3P.2.3 Actions to be taken e.g. education if patient responses deficient.
Interventions NPSA 18 AC Mar10
3P.2.4 Questionnaire results collation sheet in excel. Results NPSA 18 AC THpct Mar09
3P.2.5 CPD action plan for community pharmacists. Action plan NPSA 18 AC THpct Mar09
3S Secondary Care
3S.1.1 Barnet & Chase Farm Hospitals NHSTrust
Prereg audit abstract of incorrect dosing with low molecular weight heparin due to estimation of patient wt and prescription for unlicensed indications, e.g. AF.
Enox dose & indicn NPSA 18 AC Barnet&Chase Farm Jun2007
3S.4.1 Chelsea and Westminster Hospital NHS Foundation Trust
Prereg audit abstract on correct documentation on drug chart of AC associated details and compliance with Fennerty prescribing guidelines for medical inpatients.
3S.5.1 Colchester Hospital University NHS Foundation Trust
Prereg audit abstract on use of AC charts for patients initiated on AC & those maintained on AC during hospital admission. Includes assessment of INR control of patients being maintained.
3S.15.1 Prereg audit abstract of documentation standards on drug charts for patients post valve replacement at the Heart Hospital.
Doc stds presc NPSA 18 AC UCL Jun2009
3S.16.1 Unknown Prereg audit abstract of staff survey of competencies and information given to patients.
Competencies &patient info NPSA 18 AC DGH Jun2009
3S.17.1 The Whittington Hospital NHS Trust
Prereg audit abstract of correct initiation of warfarin with e.g.baseline INR and compliance with loading guidelines. Also linked this with number of patients with therapeutic INR at discharge.
5 Promote safe practice with prescribers and pharmacists to check that patients’ INR is being monitored regularly and that the INR level is safe before issuing or dispensing prescriptions
Reference Number
Organisation Details Where to find it Who to contact for further information
5M Mental Health Trusts
See procedures and protocols in section 2
5P Primary Care Trusts
5P.1.1 NHS Surrey Patient education section recommends they show yellow book to request repeats and to collect warfarin from community pharms.
5S.4.2 Procedure for dispensary staff requiring them to check INR in yellow book and ensure suitable strengths of tablets are prescribed before dispensing ACs for outpatients.
Promote safe practice for prescribers co-prescribing one or more clinically significant interacting medicines
Reference Number
Details Where to find it Who to contact for further information
6M Mental Health Trusts
6M.1.1 North East London NHS Foundation Trust
Policy recommends checking if a drug interacts and to avoid interacting drugs if possible. If not to monitor INR more frequently when stopping or starting such mediicines.
Section 5 of the guideline gives advice to doctors on being aware of significant interactions and actions to take on checking INR. Includes appendix - food, herbal and drug interactions.
6S.4.1 Queen Victoria Hospital NHS Foundation Trust (Provides specialist reconstructive surgery)
Recommends if interacting drugs are prescribed it is the responsibility of prescriber to monitor INR & in outpatient setting, to inform patient to have INR checked in 4-7days & to provide details of this change in therapy to their AC clinic.
Policy advices against using 5mg & 0.5mg tablets together in the same patient.
Policy NPSA 18 AC Bedfordshire Comm Mar10
8P.2.1 NHS Suffolk / Ipswich Hospitals NHS Trust
Draft guideline states they will not be issuing 0.5mg tablets to prevent errors due to patients confusing the two strengths. Constant daily dosing and not using half tablets is recommended.
Draft guideline states they will not be issuing 0.5mg tablets to prevent errors due to patients confusing the two strengths. Constant daily dosing and not using half tablets is recommended.
9 Promote the use of safe practice procedures for the administration of anticoagulants in social care settings
Reference Number
Organisation Details Where to find it Who to contact for further information
9M Mental Health Trusts
Not Applicable
9P Primary Care Trusts
9P.1.1 Bedfordshire Community Health Services
Draft policy - Covers prescribing for inpatients & outpatients, action if interacting drug is stopped or started, INR monitoring and administration of AC, discharge of patients. It advises against the use of monitored dosage devises unless risk assessment carried out by community pharmacist.
Policy NPSA 18 AC Bedfordshire Comm Mar10
9P.2.1 Unknown Commissioning toolkit for PCT commissioners. Commissioning Toolkit NPSA 18 AC Mar08
Appendix 1 Summary of the NPSA requirements (details available at www.npsa.nhs.uk )
The National Patient Safety Agency (NPSA) is recommending that NHS and independent sector organisations in England and Wales take the following steps: 1. Ensure all staff caring for patients on anticoagulant therapy have the necessary work competences. Any gaps in competence must be addressed
through training to ensure that all staff may undertake their duties safely. 2. Review and, where necessary, update written procedures and clinical protocols for anticoagulant services to ensure they reflect safe practice, and
that staff are trained in these procedures. 3. Audit anticoagulant services using BSH/NPSA safety indicators as part of the annual medicines management audit programme. The audit results
should inform local actions to improve the safe use of anticoagulants, and should be communicated to clinical governance, and drugs and therapeutics committees (or equivalent). This information should be used by commissioners and external organisations as part of the commissioning and performance management process.
4. Ensure that patients prescribed anticoagulants receive appropriate verbal and written information at the start of therapy, at hospital discharge, on
the first anticoagulant clinic appointment, and when necessary throughout the course of their treatment. The BSH and the NPSA have updated the patient-held information (yellow) booklet.
5. Promote safe practice with prescribers and pharmacists to check that patients’ blood clotting (International Normalised Ratio, INR) is being
monitored regularly and that the INR level is safe before issuing or dispensing repeat prescriptions for oral anticoagulants. 6. Promote safe practice for prescribers co-prescribing one or more clinically significant interacting medicines for patients already on oral
anticoagulants; to make arrangements for additional INR blood tests and to inform the anticoagulant service that an interacting medicine has been prescribed. Ensure that those dispensing clinically significant interacting medicines for these patients check that these additional safety precautions have been taken.
7. Ensure that dental practitioners manage patients on anticoagulants according to evidence-based therapeutic guidelines. In most cases, dental
treatment should proceed as normal and oral anticoagulant treatment should not be stopped or the dosage decreased inappropriately. 8. Amend local policies to standardise the range of anticoagulant products used, incorporating characteristics identified by patients as promoting safer
use. 9. Promote the use of written safe practice procedures for the administration of anticoagulants in social care settings. It is safe practice for all dose
changes to be confirmed in writing by the prescriber. A risk assessment should be undertaken on the use of Monitored Dosage Systems for anticoagulants for individual patients. The general use of Monitored Dosage Systems for anticoagulants should be minimised as dosage changes using these systems are more difficult.
Risk Assessment of Anticoagulant Therapy - NPSA - 2006-01-v1 - link
Risk Assessment of Anticoagulant Therapy - Risk Assessment Grid - NPSA - Jan06 - link
Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency on Safety Indicators for anticoagulant services -BJH – 2006 - link
Guidelines on the use and monitoring or heparin - BJH – 2006 - link
Anticoagulant Therapy : Information for GPs - NPSA - 2007- link
Anticoagulant therapy: Information for community pharmacists - NPSA – 2007 - link
Flyer - Anticoagulant therapy: Information for community pharmacists - NPSA - link
Anticoagulant patient safety alert - Advice for social care providers - NPSA – 2007 - link
Patient information booket on oral anticoagulant therapy - NPSA - Mar07 - link
Information booket for Dental Patients on oral anticoagulant therapy - NPSA – 2007 - link
Poster - Managing patients who are taking warfarin and undergoing dental treatment - NPSA - 2009-01-v1 - link
Record Book on oral anticoagulant therapy - NPSA – 2007 - link
Workforce competence statement: Anticoagulant competence 5: Preparing and administering heparin therapy - NPSA - 2007-03-v1 - link
Workforce competence statement: Anticoagulant competence 6: Reviewing the safety and effectiveness of an anticoagulant service - NPSA - 2007-03-v1 - link
