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Evaluation of the impact of NPSA guidance designed to improve medication safety: A baseline study of the management of anticoagulent medication

Researchers: Karin Lowson, Annette Lankshear, Paul Trueman

The study was carried out in 21 NHS Trusts in England and Wales between April and December 2007 at the same time as another designed to assess the safety of injectable medications.  The aims were:

  • To carry out a baseline audit into the management of anticoagulant medicines prior to the dissemination of the patient safety alert;
  • To identify where, if any, shortfalls in the management occurred.

We found a high degree of consensus that there were both internal and external problems in the management of anticoagulation services. The former primarily related to the perceived competence of junior doctors and nurses, particularly in relation to the management of loading dosages and of patient discharge. The external problems lay in the communication between acute trust, Primary care organisation and GP's

75% of trusts claimed to have one or more trust-wide protocols for the management of anticoagulation although these were frequently said to be out-of-date.  The main problems identified in relation to low molecular weight heparin were around dose omissions and factor 10 errors, where prescriptions for 2,500u were read as 25,000u. A striking finding was that despite the agreement amongst senior medical and pharmacy staff that junior doctors and ward nurses did not have the competence to manage inpatient anticoagulation, no-one appeared to feel empowered to take steps to correct this.