Anticoagulation Clinics: Ensuring Safety for a High-Risk Medication

Anticoagulants, which include orally administered warfarin (commonly known as Coumadin) and intravenous heparin, are prescribed to some patients to reduce the risk of thrombosis (i.e., formation of blood clots); however, the risk of adverse events, such as hemorrhage, is high if the drug is not administered properly and if patients are not sufficiently monitored. Indeed, both warfarin and heparin are included on the Institute for Safe Medication Practices' (ISMP) list of high-alert medications.1 Medications on ISMP's list pose a high risk of serious patient harm if used improperly.

Because anticoagulants are considered high-risk medications and involve complex dosing and monitoring, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) proposed requirement 3E, "Reduce the likelihood of patient harm associated with the use of anticoagulation therapy," as part of its National Patient Safety Goals (NPSGs) and requirements for 2007; however, the requirement was not approved. If passed, the requirement would have been part of existing goal 3, "Improve the safety of using medications." Even though the anticoagulation safety requirement was not put in effect for 2007, JCAHO could consider its inclusion in the future; in fact, JCAHO has begun preliminary discussions about NPSGs for 2008 and 2009, and the anticoagulation safety requirement is included with the list of goals for discussion.2

Patients must be aware of the risks associated with anticoagulation therapy and must strictly follow treatment protocols. In addition, physicians must make appropriate treatment decisions, monitor patients regularly, and follow up with patients regarding their treatment. However, consistently monitoring patients who take anticoagulation medication outside the hospital and ensuring that the anticoagulant is working correctly can be challenging for clinicians. To meet these challenges, many healthcare facilities have implemented outpatient anticoagulation clinics for patients receiving warfarin. (Heparin is primarily used in the inpatient setting; individuals on anticoagulation therapy outside the hospital receive warfarin.)

This article will provide general information on outpatient anticoagulation clinics for patients on warfarin, with a focus on a unique "virtual anticoagulation clinic" that has significantly improved patient safety and reduced costs at one facility—Abington Memorial Hospital (Abington, Pennsylvania). Elements of a formal anticoagulation clinic and Abington's Web-based clinic will be discussed, as well as benefits, costs, and considerations associated with each approach. Patient education, a necessary element of any anticoagulation management program, will also be addressed. The strategies discussed in this article deserve risk managers' attention because...