Preventing Anticoagulation Errors

Anticoagulants remain a high-alert medication due to potential for bleeding complications associated with their use. Consider these tips for safety when caring for patients receiving anticoagulants.

Abbreviations: LMWH = low-molecular-weight heparin; INR = international normalized ratio; PT = prothrombin time; PTT = partial thromboplastin time.

 

Give the Right Drug to the Right Patient

 

Make sure you have the CORRECT patient.

  • Scan the patient’s wrist band.
  • Use TWO patient identifiers (e.g., full name, medical record number, date of birth).1
 

Make sure you have the CORRECT medication.

  • Review the medication label, including the NAME and STRENGTH.
  • Scan the medication barcode BEFORE giving it to the patient.
 

Ensure Accurate Doses

 

Verify patient weights. Make sure documented weights make sense for each patient, as weights affect initial weight-based doses.

  • For example a therapeutic enoxaparin dose (1 mg/kg) for a 100 kg patient is 100 mg, versus 45 mg for a 100 pound patient.
  • See our resource, Obtaining Accurate Patient Weights, for helpful tips.
 

Perform double-checks, per policy.

  • Anticoagulants often require double verification before doses are administered or heparin drip rates are changed.
 

Use programmable pumps (e.g., smart pumps) for heparin infusions.1

 

Pay special attention when using prefilled syringes.

  • Some patients will only receive PART of a prefilled syringe for their dose.
    • Example: You might receive an enoxaparin (Lovenox) 80 mg prefilled syringe for a 70 mg dose.
  • Some patients may require more than one prefilled syringe for their dose.
    • Example: You will need more than one prefilled syringe for enoxaparin (Lovenox) doses >150 mg.
 

Watch for Duplicates

 

It is sometimes appropriate to use TWO different anticoagulants at the same time.

  • For example: You might see heparin or LMWH used WITH warfarin until after achieving an INR of 2 or more for two days.
 

However, consider contacting the prescriber if you see injectable anticoagulants in patients on a new oral anticoagulant (apixaban [Eliquis], dabigatran [Pradaxa], edoxaban [Savaysa], rivaroxaban [Xarelto]) or with other injectable anticoagulants.

 

Be Prepared for Switches

 

The timing of doses will vary based on which anticoagulants you are switching to and from.

  • Check with your pharmacist to clarify when the first dose of the new anticoagulant should be given.
    • For example: When switching from a treatment dose of LMWH (e.g., enoxaparin 1 mg/kg) to a heparin drip, the drip should be started when the next dose of LMWH would have been due.2
      • It’s not unusual to omit bolus heparin doses in this situation.2
    • For example: When switching from a heparin drip to LMWH the first injection should be given ­≤2 hours AFTER stopping the infusion.2
  • For details on transitions to and from other anticoagulants, go to: http://www.thomasland.com/AnticoagTransitions_2016.pdf.
 

Avoid Omissions

 

Watch for most anticoagulants to be restarted after being held for a procedure.

  • The timing may vary based on multiple factors including bleeding risk from procedure, medication, etc.
    • For example: Expect to wait ≥6 hours before restarting any anticoagulation after removing spinal/epidural anesthesia.4
    • For example: Expect to see the newer oral anticoagulants started within 24 to 72 hours after surgeries or procedures.4
 

Monitor Anticoagulants Appropriately

 

Be familiar with baseline labs for anticoagulants (e.g., prothrombin time [PT], INR, PTT, complete blood count [CBC], platelets).

Some anticoagulants require renal monitoring.

  • For example: Rivaroxaban (Xarelto) may not be appropriate for patients with significant kidney disease or acute renal failure.
 

Follow protocols to time lab draws appropriately with heparin drips.

  • For example: Expect to draw PTTs about four to six hours AFTER bolus heparin doses and rate changes.3
 

Obtain appropriate samples for PTT testing.

  • Avoid using the line or arm where heparin is infused to draw PTT levels.3
  • Draw adequate waste to clear lines flushed with heparin before drawing samples.3
 

Lab values can indicate a possible adverse drug reaction.

 

Ensure Safe Transitions to Outpatient Use of Anticoagulants

 

Educate patients, families, and caregivers about safe anticoagulation.

  • Emphasize the importance of adherence with the anticoagulants and any necessary monitoring.
    • For example: Missing even one dose of a new oral anticoagulant can increase the risk of clots or stroke.5
  • Discuss bleeding risk (e.g., easier bleeding/bruising, nose bleeds) with patients, so they know what to expect.
 

Teach patients proper injection technique, if being discharged on LMWH.

 

Provide relevant handouts for patients to take home with them.

Project Leader in preparation of this clinical resource (330350): Beth Bryant, Pharm.D., BCPS, Assistant Editor

References

  1. The Joint Commission. National patient safety goals effective January 2017: hospital accreditation program. https://www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_Jan2017.pdf. (Accessed February 14, 2017).
  2. Hellerslia V, Mehta P, Rudd K. Transition of anticoagulants 2016. http://www.thomasland.com/AnticoagTransitions_2016.pdf. (Accessed February 14, 2017).
  3. Children’s Mercy. Standard heparin management care process model. Revised May 2016. https://www.childrensmercy.org/library/uploadedFiles/childrensmercyorg/Health_Care_Professionals/
    Medical_Resources/Evidence_Based_Practice/Anticoagulation_Therapy/Heparin/Synopsis/Standard%
    20Heparin%20Management.pdf
    . (Accessed February 14, 2017).
  4. Horlocker TT, Wedel DJ, Rowlingson JC, et al. Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (third edition). Reg Anesth Pain Med 2010; 35:64-101.
  5. Clemens A, Noack H, Brueckmann M, Lip GY. Twice- or once-daily dosing of novel oral anticoagulants for stroke prevention: a fixed-effects meta-analysis with predefined heterogeneity quality criteria. PLos One 2014;9:e99276.

Cite this document as follows: Clinical Resource, Preventing Anticoagulation Errors. Nurse’s Letter/Hospital Pharmacist’s Letter. March 2017.

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