implementing npsa requirements: anticoagulant therapy · 2020-03-01 · medicines use and safety...
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East & South East England Specialist Pharmacy Services
East of England, London, South Central & South East Coast
Medicines Use and Safety
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 1
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Implementing NPSA Requirements: Anticoagulant Therapy
A Resource to Support the Implementation of NPSA recommendations: Patient Safety Alert 18: Actions that can make anticoagulant therapy safer
©East and South East England Specialist Pharmacy Services
Medicines Use and Safety
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 2
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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
training pre-registration pharmacist leads.
Medicines Use and Safety
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 3
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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
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 4
1 Ensure all staff caring for patients on anticoagulant therapy have the necessary work competencies Reference Number
Organisation Details Where to find it Who to contact
1M Mental Health Trusts
1M.1.1 North East London NHS Foundation Trust
Prescribing of ACs is uncommon in a mental health trust settings and pharmacist carries out staff education when there is a patient.
Policy NPSA 18 AC NELondonFT Aug08
1M.2.1 Sussex Partnership NHS Foundation Trust
Since AC use is infrequent ward managers are responsible for getting staff to read the AC guidelines when there is a patient needing ACs.
Guide NPSA 18 AC Sussex Partnership Nov09
1P Primary Care
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.
Guidelines NPSA 18 AC Surrey PCT Jul2009
1S Secondary Care
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.
Policy NPSA 18 AC QueenVictoriaFTMar 09
1S.2.1 Western Sussex Hospitals NHS Trust
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.
Action Plan NPSA 18 AC WSussex Mar09
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 5
2 Review and update procedures and protocols to ensure they reflect safe practice and that staff are trained to implement them
Reference Number
Organisation Details Where to find it Who to contact
2M Mental Health Trusts
2M.1.1 North East London NHS Foundation Trust
Mental Healthcare Trust policy which prohibits use of unfractionated heparin in this trust.
Warfarin doses to be prescribed in patient’s yellow AC book as well as on inpatient chart.
Yellow AC book is paper clipped to the drug chart for any patient on AC.
Staff trained by pharmacist as and when there is an AC patient.
Policy NPSA 18 AC NELondonFT Aug 08
2M.2.1 Suffolk Mental Health Partnership NHS Trust
BNF size guide on prescribing AC with lots of pointers suggesting who to contact.
Pocketguide NPSA 18 AC SMHP Sep2008
2M.3.1 Surrey and Borders Partnership NHS Foundation Trust
Draft procedure which was produced by adaptation from 2M.4.1.
Proc NPSA 18 AC Surrey Mar10
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.
Guide NPSA 18 AC Sussex Partnership Nov09
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 6
Reference Number
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.
Policy NPSA 18 AC Bedfordshire Comm Mar10
2P.2.1 NHS Brent
Questionnaire to be completed by patient before AC clinic dosing, especially useful for postal clinics.
Questionnaire NPSA 18 AC Brent Mar10
2P.3.1 NHS Suffolk / Ipswich Hospitals NHS Trust
Guidelines covering AC. Appendix contains their recommendations for target INR for different heart valve replacement types.
Guidelines NPSA 18 AC IpsSuff Mar10
Depending on if patient in primary or secondary care readers are directed to appropriate section of guidelines.
Flow gp hosp NPSA 18 AC IpsSuff Mar10
2P.4.1 NHS Surrey A comprehensive AC guideline produced in liason with local hospitals. States doctors, nurses and pharmacists responsibilities.
Guidelines NPSA 18 AC Surrey PCT Jul2009
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 7
Reference Number
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,.
Policy NPSA 18 AC Barking Jul09
2S.2.1 Barts & The London NHS Trust
Comprehensive action plan. Recommends patients monitored by hospital OP clinic, present yellow book each time requesting warfarin repeat prescription as proof of monitoring.
Action Plan NPSA 18 AC BLT Jun07
2S.2.2
Standards state systematically what clinical pharmacists need to do on a day to day basis for in-patients.
Pharm Std NPSA 18 AC BLT Aug07
2S.3.1 Dartford and Gravesham NHS Trust
Action plan recommends interacting medications are documented in yellow AC book for those patients who are already on warfarin.
Action Plan NPSA 18 AC Darent Jun07
[email protected] 2S.3.2 Overview – AC drug chart must be completed
before AC is dispensed. Acreditted medicines management technicians, pharmacists, doctors or nurses carry out counselling.
Overview NPSA 18 AC Darent Mar10
2S.3.3 Copy of anticoagulation prescription chart for in-patients, out-patients & day cases.
Inpatient Pres NPSA 18 AC Darent Oct2008
2S.3.4 Discharge form to ensure necessary steps for seamless transfer of care are undertaken, including counselling.
Safe discharge form NPSA 18 AC Dartford Oct 2008
2S.4.1 Heatherwood & Wexham Park NHS Foundation Trust
Business case to fund additional AC practitioners to carry out in-patient dosing safely.
OBC thromb prac NPSA 18 AC Wexham Oct07
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Reference Number
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.
Launch NPSA 18 AC Wexham Mar09
2S.4.3 Flow diagram showing inpatient dosing. Algorithm NPSA 18 AC Wexham Oct08
2S.4.4 Inpatient referral form to AC team. Deliberately kept simple to make referring easier for doctors.
Referal form NPSA 18 AC Wexham Mar10
2S.4.5 Transfer letter for patients who on discharge can be referred to primary care clinics.
Transfer ltr NPSA 18 AC Wexham Mar10
2S.5.1 Ipswich Hospitals NHS Trust / NHS Suffolk
Guidelines covering AC. Appendix contains their recommendations for target INR for different heart valve replacement types.
Guidelines NPSA 18 AC IpsSuff Mar10
Depending on if patient in primary or secondary care readers are directed to appropriate section of guidelines.
Flow gp hosp NPSA 18 AC IpsSuff Mar10
2S.6.1 Luton & Dunstable Hospital NHS Foundation Trust
Overview – states counselling checklists, discharge checklist and warfarin labels for front of drug chart all in yellow to be consistent.
Overview NPSA 18 AC Luton Mar10
2S.6.2 This is an algorith of actions for pharmacists and pharmacy technicians when dealing with in-patients on oral anticoagulants.
Pharm algorith NPSA 18 AC Luton Jan 09
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 9
Reference Number
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.
Policy NPSA 18 AC QueenVictoriaFTMar 09
2S.8.1 St George’s Healthcare NHS Trust
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
2S.9.1 University College London Hospitals NHS NHS Foundation Trust
Admission checklist now incorporated into the inpatient drug chart to be completed by pharmacists.
Admission checks NPSA 18 AC UCLH May 08
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 10
Reference Number
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.
Action Plan NPSA 18 AC WSussex Mar09
2S.10.2 NPSA style Newsletter for trust staff including actions to be taken by ward clerks.
Newsletter NPSA 18 AC WSussex May09
2S.10.3 AC prescription chart, printed on pink paper, which doubles up as a referral form for the AC clinic on discharge.
Presc NPSA 18 AC WSussex Mar10
2S.10.4 Procedure for pharmacists. Proc NPSA 18 AC WSussex Feb09
2S.10.5 Alphabetical interactions with warfarin list and action to take.
Interactions NPSA 18 AC WSussex Oct09
2S.10.6 Audit results for OP AC clinic run by consultant haematologist or SpR.
Audit NPSA 18 AC WSussex Nov08
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 11
3 Audit anticoagulant services using BSH/NPSA safety indicators as part of the annual medicines management audit programme
Reference Number
Organisation Details Where to find it Who to contact
3M Mental Health Trusts
No details available for this section
3P Primary Care Trusts
3P.1.1 NHS Surrey Appendix 6 covers evaluation of the service by the PCT.
Guidelines NPSA 18 AC Surrey PCT Jul2009
3P.2.1 NHS Tower Hamlets Background, rationale, audit standards, method to AC audit to be administered by community pharmacists.
Method NPSA 18 AC THpct Jan09
[email protected] or [email protected]
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.2.1 Barts & The London NHS Trust
Uses monthly audit of 20 in-patients to assess compliance with NPSA safety indicators.
Action Plan NPSA 18 AC BLT Jun07
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 12
Reference Number
Organisation Details Where to find it Who to contact
3S.3.1 Imperial College Healthcare NHS Trust
Prereg audit abstract of inpatient counselling and patient knowledge warfarin questionnaire.
Inpatient counselling NPSA 18 AC Charing Cross Jun2009
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.
Pres med inpatients NPSA 18 AC C&W Jun2006
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.
Pres completion NPSA 18 AC Colchester Jun08
3S.5.2 Prereg audit abstract on use of AC charts & patient information prior to first dose.
Safety initiatives NPSA 18 AC Colchester Jun2009
3S.6.1 Imperial College Healthcare NHS Trust
Prereg audit abstract of completion of AC books prior to discharge with up to date dose.
Patient records NPSA 18 AC Hammersmith Jun07
3S.7.1 King's College Hospital NHS Foundation Trust
Prereg audit abstact of causes & management of over-anticoagulation.
Causes & Mx of over AC NPSA 18 AC Kings Jun2006
3S.8.1 Kingston Hospital NHS Trust
Prereg audit abstract of local AC guidelines adherance and drug chart completion .
Guidelines audit NPSA 18 AC Kingston Jun09
3S.9.1 North Middlesex University Hospital NHS Trust
Prereg audit abstract of OP clinic patient questionnaire to assess couselling & patient understanding.
Counselling NPSA 18 AC NMiddlesexJun2008
3S.10.1 Oxford Radcliffe Hospitals NHS Trust
Audit with haematology dept of raised INRs of thousands of patients.
INR above5 NPSA 18 AC Oxford Mar10
3S.11.1 South London Healthcare NHS Trust
Prereg audit abstract of compliance with prescribing protocol, documentation on drug chart.
Pres protocol compliance NPSA 18 AC Queen Elizabeth Hospital Jun2008
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 13
Reference Number
Organisation Details Where to find it Who to contact
3S.12.1 Epsom and St Helier University Hospitals NHS Trust
Prereg audit abstract of compliance with loading protocol and number of patients therapeutic at discharge.
LD & INR NPSA 18 AC St Helier hosp Jun2009
3S.13.1 Imperial College Healthcare NHS Trust
Prereg audit abstract of % of warfarin doses prescribed before 6pm in line with trust policy.
Timely inpatient pres NPSA 18 AC St Marys Jun2007
3S.14.1 South London Healthcare NHS Trust
Prereg audit abstract on advice given to AC patients pre-op.
PreAdClinics AC advice NPSA 18 AC Bromley Jun09
[email protected] or [email protected]
3S.14.2 University College London Hospitals NHS NHS Foundation Trust
Prereg audit abstract of admission documentation and discharge plan.
Adm & disch doc NPSA 18 AC UCL Jun2007
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.
Initiation of warf NPSA 18 AC Whittington Jun2006
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 14
4
Ensure patients receive appropriate verbal and written information especially on initiation of anticoagulation and hospital discharge
Reference Number
Details Where to find it Who to contact for further information
4M Mental Health Trusts
4M.1.1 North East London NHS Foundation Trust
Requires patients are given verbal and written information on page 2.
Policy NPSA 18 AC NELondonFT Aug 08
4M.2.1 Surrey and Borders Partnership NHS Foundation Trust
Recommends doctors ensure patient understands reasons for AC and monitoring requirements. (Adapted from 4M.3).
Proc NPSA 18 AC Surrey Mar10
4M.3.1 Sussex Partnership NHS Foundation Trust
Recommends doctors ensure patient understands reasons for AC and monitoring requirements.
Guide NPSA 18 AC Sussex Partnership Nov09
4P Primary Care Trusts
4P.1.1 NHS Surrey Page 11 covers patient education and appendix 10 contains a questionnaire for patients to complete AC clinic consultation.
Guidelines NPSA 18 AC Surrey PCT Jul2009
4S Secondary Care
4S.1.1 Barking Havering & Redbridge University Hospitals Trust
Policy contains counselling record sheet. Policy NPSA 18 AC Barking Jul09
4S.2.1 Dartford and Gravesham NHS Trust
Discharge form contains counselling tick list. Safe discharge form NPSA 18 AC Dartford Oct 2008
4S.3.1 Luton & Dunstable Hospital NHS Foundation Trust
Counselling tick list to be completed and filed in patient notes. Also contains information to be imparted on reverse.
Counselling form NPSA 18 AC Luton April 09
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 15
Reference Number
Details Where to find it Who to contact for further information
4S.4.1 Queen Victoria Hospital NHS Foundation Trust (Provides specialist reconstructive surgery)
Counselling and actions to be taken to ensure safe AC for inpatients and at discharge by pharmacists. Appendix 2 is nurse SOP to administer warfarin.
Policy NPSA 18 AC QueenVictoriaFTMar 09
4S.5.1 St George’s Healthcare NHS Trust
Prescription proforma: Page 4 contains checklists for prescribers, nurses and pharmacists and safe transfer of monitoring checks to be signed.
Presc p4 NPSA 18 AC St Georges Mar10
4S.6.1 University College London Hospitals NHS NHS Foundation Trust
Counselling checklist incorporating counselling information to be filed in notes on completion.
Counselling record NPSA 18 AC UCLH Jun 07.doc
4S.7.1 Western Sussex Hospitals Trust
Colour chart to be given to patients with their yellow books which pictorially shows which tablets to take for a given dose prescribed in mg.
Mg dose tabs NPSA 18 AC WSussex Mar10
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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.
Guidelines NPSA 18 AC Surrey PCT Jul2009
5S Secondary Care
5S.1.1 Barking Havering & Redbridge University Hospitals Trust
Standards for pharmacists on p33-34 state dispense once ensured INR being checked.
Policy NPSA 18 AC Barking Jul09
5S.2.1 Barts & The London NHS Trust
Pharmacist standards state pharmacists should check INRs on a day to day basis.
Pharm Std NPSA 18 AC BLT Aug07
5S.3.1 Dartford and Gravesham NHS Trust
Copy of anticoagulation prescription chart for in-patients, out-patients & day cases to be completed before dispensing.
Inpatient Pres NPSA 18 AC Darent Oct2008
5S.4.1 Heatherwood & Wexham Park Hospitals NHS Foundation Trust
Anticoagulant section of drug chart so that pharmacists can check readily whether INR is being checked.
Inpatient and Admin Chart NPSA 18 AC HWPH Jun 08
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.
Disp warf NPSA 18 AC Wexham Jan08
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 17
Reference Number
Details Where to find it Who to contact for further information
5S.5.1 Luton & Dunstable Hospital NHS Foundation Trust
Dispensing procedure requires INR checks before dispensing.
Disp proc NPSA 18 AC Luton Nov 09
5S.6.1 Queen Victoria Hospital NHS Foundation Trust (Provides specialist reconstructive surgery)
Standards for pharmacists state ensure INR being checked and dosing appropriate.
Policy NPSA 18 AC QueenVictoriaFTMar 09
5S.7.1 Western Sussex Hospitals Trust
Procedure for pharmacists requires INR recording on AC prescription and doses are appropriate before dispensing.
Proc NPSA 18 AC WSussex Feb09
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 18
6
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.
Policy NPSA 18 AC NELondonFT Aug 08
6M.2.1 Surrey and Borders Partnership NHS Foundation Trust
On page 5 it describes how doctors need to be aware of significant interactions including prn medicines.
Proc NPSA 18 AC Surrey Mar10
6M.3.1 Sussex Partnership NHS Foundation Trust
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.
Guide NPSA 18 AC Sussex Partnership Nov09
6P Primary Care Trusts
See procedure and proctocols in section 2
6S Secondary Care
6S.1.1 Barking Havering & Redbridge University Hospitals Trust
Standards for pharmacists and doctors require they check INR appropriatley with consideration to clinical status and interacting drugs.
Policy NPSA 18 AC Barking Jul09
6S.2.1 Barts & The London NHS Trust
Pharmacist standards require regular INR checks appropriately based on general health and interacting drugs.
Pharm Std NPSA 18 AC BLT Aug07
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 19
Reference Number
Details Where to find it Who to contact for further information
6S.3.1 Dartford and Gravesham NHS Trust
Action plan recommends interacting medications are documented in yellow book for those patients who are already on warfarin.
Action Plan NPSA 18 AC Darent Jun07
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 NPSA 18 AC QueenVictoriaFTMar 09
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 20
7 Ensure dental practitioners manage patients according to evidence based medicine
Reference Number
Details Where to find it Who to contact for further information
7M Mental Health Trusts
No documents available
7P Primary Care Trusts
7P.1.1 NHS Suffolk / Ipswich Hospitals NHS Trust
Section 12.0 - advice for dentists. Guidelines NPSA 18 AC IpsSuff Mar10
7P.2.1 NHS Surrey Appendix 8 - information for dentists. Guidelines NPSA 18 AC Surrey PCT Jul2009
7S Secondary Care
7S.1.1 Ipswich Hospitals NHS Trust / NHS Suffolk
Section 12.0 - advice for dentists. Guidelines NPSA 18 AC IpsSuff Mar10
7S.2.1 Queen Victoria Hospital NHS Foundation Trust (Provides specialist reconstructive surgery)
Trust leaflet for dental outpatients (appendix 3) which includes advice on reducing risk of bleeding after dental surgery and preferred analgesia.
Policy NPSA 18 AC QueenVictoriaFTMar 09
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 21
8 Amend procedures to standardise the range of anticoagulant products used
Reference Number
Organisation Details Where to find it Who to contact for further information
8M Mental Health Trusts
8M.1.1 North East London NHS Foundation Trust
Recommends use of standard preparations. Policy NPSA 18 AC NELondonFT Aug 08
8M.2.1 Surrey and Borders Partnership NHS Foundation Trust
Section 3.3 recommends use of standard preparations.
Proc NPSA 18 AC Surrey Mar10
8M.3.1 Sussex Partnership NHS Foundation Trust
Section 2 recommends use of standard preparations.
Guide NPSA 18 AC Sussex Partnership Nov09
8P Primary Care Trusts
8P.1.1 Bedfordfordshire Community Health Services
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.
Guidelines NPSA 18 AC IpsSuff Mar10
8S Secondary Care
8S.1.1 Ipswich Hospitals NHS Trust / NHS Suffolk
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.
Guidelines NPSA 18 AC IpsSuff Mar10
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 22
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
9S Secondary Care
Not Applicable
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 23
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.
Implementing NPSA requirements: Anticoagulant therapy Vs2 – Jul11 (JN) 24
Appendix 2
Anticoagulant Therapy Patient Safety Alert - NPSA - Mar07 - link
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
Anticoagulant Treatment Record Vs1 - NPSA - link
Patient Briefing - NPSA - Mar07 - link
Audit Checklist - NPSA - Mar07 - link
Workforce competence statement: Anticoagulant competence 1: Initiating anticoagulant therapy - NPSA - 2007-03-v1 - link
Workforce competence statement: Anticoagulant competence 2: Maintaining oral anticoagulant therapy - NPSA - 2007-03-v1 - 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