ISMP Canada

Institute for Safe Medication Practices Canada

Hospital Self-Assessment for Anticoagulant Safety

Demographics

1. Province
2. Please check the one category that best describes the number of beds currently set up and staffed for use in your hospital.
Less than 50
50 to 99
100 to 299
300 to 499
500 or more
3. Please check the one category that best describes the type of service that your hospital provides to the majority of its admissions.
General medical and surgical
Specialty: psychiatric
Specialty: rehabilitation
Specialty: pediatric
Specialty: oncology
Other
4. Please check the one category that best describes your hospital type.
Teaching
Community
Other
5. Does your hospital provide any of the following services? (Check all that apply.)
Oncology (check even if chemotherapy is administered infrequently)
Pediatrics (check even if pediatric care is provided only in the emergency department or outpatient surgery)
Neonatal intensive care (check for any level of service)
Trauma services (check for any level of service)
6. Is your hospital one of several in a healthcare system or corporation with common governance?
Yes
6a. How many hospitals comprise your health system?
2 - 5
6 - 10
More than 10
No
7. Has your hospital previously completed a Medication Safety Self-Assessment?
Yes
No
8. Which, if any, of the following ISMP Canada-supported tools or services have you used or accessed?
ISMP Canada Safety Bulletins
ISMP (US) Medication Safety Alert! (published by ISMP in the US)
Online medication incident or near miss reporting
Analyze-ERR ®
Root cause analysis (RCA) workshop
Failure mode and effects analysis (FMEA) workshop
System Safeguards to Prevent Error Induced Injury with Potassium Chloride (binder)
System Safeguards to Prevent Error-Induced Injury with Narcotics (Opioids) (binder)
  1. A There has been no activity to formally discuss this strategy or intervention
  2. B This strategy or intervention has been discussed but there has been no activity to implement
  3. C This strategy or intervention is developed but not yet routinely utilized
  4. D This strategy or intervention is fully implemented and part of routine practice
  5. N/A Not applicable to my hospital

1. Current Strategies

  		ABCDN/A
1
The institution has an organization-wide, written policy or guideline for the prevention of Venous Thromboembolism (VTE)
2
The institution has a written policy or guideline for VTE prevention for specific group(s), e.g. intensive care unit (ICU), orthopaedics, etc. but is not organization wide
3
The institution has identified specific targets or goals with respect to VTE prevention either overall or for specific patient groups
4
Pharmacists within the institution are involved in the management of patients at risk of VTE (involved in the identification of patients at risk, recommending or ordering thromboprophylaxis or assessing thromboprophylaxis use)
5
VTE prevention options are included in all institutional pre-printed order sets (where relevant)
6
The institution's Computerized Provider Order Entry (CPOE system) (if relevant) generates alerts or reminders that require prescribers to assess patients for risk of VTE
7
The CPOE system requires providers to make a decision to order thromboprophylaxis or to opt out of thromboprophylaxis
8
The CPOE system has embedded clinical decision support (e.g. dosing recommendations, etc.) for VTE prevention
9
The institution provides formal education to staff (pharmacists, medical and nursing staff) regarding VTE prevention
10
The institution provides education to trainees (if applicable) and new staff regarding VTE prevention
11
The institution provides patients with information about the risks of VTE on hospital admission or in a preoperative information booklet
12
The institution provides patients with information about the risks of VTE on hospital discharge that includes specific mention of symptoms of VTE and advises patients of what to do if these arise
13
The institution has performed at least one audit of appropriate VTE prophylaxis use among at least one group of hospitalized patients in the past year
14
A feedback cycle (if audit was performed) was incorporated to disseminate the results of the VTE prophylaxis audit to the relevant clinical core staff
15
The results of the audit (if performed) have been used to guide improvements to patient care
16
The institution performs ongoing VTE prophylaxis audits (at least one patient group at least once a year)
17
The institution has a multidisciplinary thromboembolism or anticoagulant committee (defined as at least one physician, one pharmacist and one nurse) with a responsibility to guide decisions and/or provide support related to thromboembolism or anticoagulation
18
High-dose unfractionated heparin (UFH) (10,000 units/mL in 5 mL vials AND 25,000 units/mL in 2 mL vials) have been removed from patient care areas
19
The availability of UFH in concentrations of 10,000 units/mL and 1,000 units/mL in 10mL vials has been reviewed and reduced
20
Availability of UFH products has been simplified and standardized across the institution
21
The pharmacy staff implements safeguards to segregate high concentration UFH in the pharmacy to reduce chances of mix-ups and errors
22
The institution provides education to practitioners who prescribe and/or monitor anticoagulant therapy and competency evaluation is conducted to demonstrate proficiency
23
The institution provides education to trainees (If applicable) about anticoagulant therapy and supervised prescribing and monitoring is part of their experience
24
The institution provides education to staff (physicians, nursing and pharmacy staff) involved in direct patient care regarding the diagnosis and management of HIT or has a service in place to provide this
25
The institution has performed one or more audits of HIT among hospitalized patients in the last two years
26
A feedback cycle (if audit was performed) was incorporated to disseminate the results of HIT audit
27
The results of the HIT audit (if performed) have been used to make improvements to patient care (if appropriate)
28
There is a formal dissemination process in place to provide health care professionals involved in the prescribing or monitoring of anticoagulant therapy with information about errors or near misses related to anticoagulants within the institution
29
There is an interdisciplinary team that reviews the literature for evidence-based practices or technologies that have been proven to be effective in reducing anticoagulant errors and improving patient outcomes to determine if changes need to be made in the care provided by providers in the institution
30
All protocols, pathways, guidelines, nomograms, order sets, flow sheets, and/or checklists for anticoagulant therapy are reviewed at least annually and revised when significant new information becomes available
  1. A There has been no activity to make this part of routine practice
  2. B This practice is routine for a small proportion (< 25%) of patients
  3. C This practice is routine for some (25-50%) patients
  4. D This practice is routine for most (50-90%) patients
  5. E This practice is routine for all patients
  6. N/A Not applicable to my hospital

2. Current Practice

  		ABCDEN/A
Please answer one of the following: 
31a
The institution accepts that all hospitalized patients are at risk for VTE and documents any patients for whom VTE prophylaxis is not indicated
OR 
31b
The institution utilizes a mandatory VTE risk assessment tool for all inpatients and this is documented in the medical record
32
Patients admitted for major general surgery are prescribed one of the following for VTE prevention:
  • LDUH bid
  • LDUH tid
  • LMWH
  • Fondaparinux
  • For patients at high risk of bleeding, properly fitted GCS or IPC (with daily reassessment for conversion to anticoagulant)
33
Patients admitted for major gynaecologic surgery are prescribed one of the following for VTE prevention:
  • LDUH bid
  • LDUH tid
  • LMWH
  • fondaparinux
  • For patients at high risk of bleeding, properly fitted GCS or IPC (with daily reassessment for conversion to anticoagulant)
34
Patients admitted for knee replacement surgery are prescribed one of the following for VTE prevention with 24 hrs of surgery:
  • LMWH
  • Fondaparinux
  • Adjusted dose warfarin with a target INR in the range of 2-3
  • Dabigatran
  • Rivaroxaban
35
Patients admitted for hip replacement surgery are prescribed one of the following for VTE prevention within 24 hrs of surgery:
  • LMWH
  • Fondaparinux
  • Adjusted dose warfarin with a target INR in the range of 2-3
  • Dabigatran
  • Rivaroxaban
36
Patients admitted for hip fracture surgery are prescribed one of the following for VTE prevention within 24 hrs of surgery:
  • LDUH bid or tid
  • LMWH
  • Fondaparinux
  • Adjusted dose warfarin with a target INR of 2.5 (range 2-3)
37
For patients undergoing major orthopaedic surgery who receive adjusted-dose warfarin for VTE prevention, a dosing system is in place and is used routinely (e.g. dosing algorithm, pharmacy or other dosing service, etc.)
38
Patients undergoing major orthopaedic surgery (hip fracture surgery, hip or knee replacement surgery) are prescribed at least 10 days of thromboprophylaxis (in hospital and/or post-discharge)
39
Patients undergoing orthopaedic surgery who require post-discharge prophylaxis are identified while in hospital and a formal, routine mechanism is in place to provide appropriate post-discharge prophylaxis to these patients
40
Patients admitted to General Internal Medicine are prescribed one of the following for VTE prevention:
  • LDUH bid or tid
  • LMWH
  • fondaparinux
  • For patients at high risk of bleeding, properly fitted GCS or IPC (with daily reassessment for conversion to anticoagulant)
41
Patients admitted to the Intensive Care Unit(s) (ICU) are prescribed one the following for VTE prevention:
  • LDUH
  • LMWH
  • For patients at high risk of bleeding, properly fitted GCS or IPC (with daily reassessment for conversion to anticoagulant)
42
Whenever possible, alternate products or procedures that do not involve heparin are used for flushing and locking of venous and arterial access lines
43
Prior to ordering any heparin product (including flushes, heparin-coated catheters, LMWH, etc.), prescribers specifically ask patients if they have a known history of Heparin Induced Thrombocytopenia (HIT) and/or an allergy to heparin and positive responses are documented in the medical record
44
The hospital formulary limits the variety of heparin products available in the institution
45
An audit has been conducted to review the heparin products and quantities stored in all areas of the hospital
46
The availability of heparin infusions is limited to fixed concentrations available in pre-mixed bags
47
For patients receiving IV heparin, an IV heparin dosage-adjustment nomogram is used which includes aPTT monitoring and appropriate adjustments of heparin infusion rates in response to the aPTT values
48
Prior to initiating therapy with IV heparin, a baseline haemoglobin and platelet count are obtained
49
Prior to initiating therapy with LMWH, a baseline haemoglobin, serum creatinine and platelet count are obtained
50
For patients on IV heparin, routine platelet monitoring is done at least every 2 days
51
For patients on heparin whose platelet counts drop > 30%, a routine mechanism is in place to begin an investigation for potential HIT and to ensure that all sources of heparin are discontinued
52
For a patient with a confirmed diagnosis of HIT, an institution-wide policy or guideline exists for management
53
The institution has a formal, routine program in place to inform patients and their caregivers that the patient has a diagnosis of HIT
54
At the time of hospital discharge for patients on warfarin, a formal patient education program is in place related to safe warfarin use
55
At discharge, patients on warfarin therapy receive written information (at an 8th grade reading level or below) about safe warfarin therapy at discharge
56
At discharge, patients on warfarin receive a written list of warfarin doses they received while in hospital (at least the last week)
57
At discharge, patients on warfarin receive a written list of their INR results while in hospital (at least the last week)
58
At discharge, patients on warfarin receive written instructions of when they should have their next INR
59
At discharge, patients on warfarin receive written instructions on what dose(s) of warfarin to take until their next INR
60
At discharge, the physician or outpatient anticoagulant clinic that will be supervising the patient's anticoagulation is contacted with information about doses and INRs for transfer of care
61
Pharmacists can automatically modify anticoagulant therapy doses in response to INR results as specified by medical directives
62
There is a hospital-wide protocol for the reversal of supra-therapeutic INR values
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