TCPS Regional Meeting ADE Breakout Session 2014
Anticoagulant Case Study
The Patient Safety Committee that consists of a clinical pharmacist, risk manager,
quality director and a nurse from the med/surg unit are completing safety rounds today
at Community General Hospital in Anytown, Tennessee. During their safety rounds
they encounter several situations involving anticoagulants that the group feels are gaps
within their facility that could lead to adverse patient events. The group decides to
conduct a planning session and utilize a new developed Medication Safety
Anticoagulation and VTE Adverse Event Gap Analysis by the Tennessee Pharmacist
Coalition to address specific gaps in their facility.
1) The group starts their safety rounds in the ER. While in the ER the group traces a
recently admitted patient that has a suspected DVT. The ER physician has ordered a
weight based heparin protocol and the RN must give 5,000 units of heparin IV as a
bolus before the drip starts. The automated dispensing cabinet is stocked with 10mL
multi-dose vials of heparin that contain a total of 10,000 units of heparin per vial. The
group observes the RN draw up the heparin to give to the patient. The RN only draws
up 0.5mL from the 10mL multi-dose vial of heparin. Upon question by the clinical
pharmacist as to why she was only going to give 500 units versus the 5,000 unit
ordered dose of heparin. The RN states that vial contains 10,000 units per mL. The RN
was not aware of the label changes that were mandated in 2012 that requires ALL
heparin products to present the total amount of drug per vial on the manufacturer label.
The actual concentration of the vial the RN was using was 1,000 units per mL. The
near miss with the bolus dose of heparin is caught and corrected before reaching the
patient.
2) While touring the cath lab department the group finds a card taped to the wall with a
handwritten list of the interventional cardiologist names and the concentrations of their
preferred heparin flush for cath procedures. The group questions one of the cath lab
RNs and further finds a cabinet stocked with heparin vials in several concentrations and
sizes. The clinical pharmacist was not aware of this cabinet.
3) The group next moves to the OR and traces a patient from the med/surg floor to the
preop staging area for a cholecystectomy. The group review todays MAR of
medications that haven been given at the 0900 med pass. The risk manager questions
what is Eliquis? The clinical pharmacist informs the group this is a new novel
anticoagulant. The group asks the preop RN if the MD is aware that the patient
received their Eliquis this am. A call is made to the physician and the elective surgery is
postponed for 24 hours and Eliquis is held till after surgery. The group questions how
physicians are notified of patients that are on anticoagulants prior to surgery. They also
question the lack of possible knowledge of the new novel anticoagulants.
4) After leaving the surgery department the group moves to the step down unit and
traces a new diagnosed Afib patient that has been started on Coumadin therapy along
with bridge therapy with Lovenox. The noticed that dietary was delivering the patient’s
lunch tray that consisted of a spinach salad with raspberry vinaigrette. In the computer
the diet for the patient had not been updated to include the newly added Coumadin
therapy. Upon review of patient’s labs since admission there were no baseline platelets
for the Lovenox therapy. The quality director asked the nurse from med/surg if she
could order baseline labs for patients on anticoagulants without a physician’s order.
The nurse informs the new quality director that they hospital does not have a protocol
for nurse/pharmacist to order baseline anticoagulant labs.
5) While on the step down unit the group finds three different heparin weight based
protocols in the standing orders that are printed on the floor for the physicians. The
quality director questions the clinical pharmacist why there are three weight based
heparin orders. The clinical pharmacist states, “They have been trying to get on
standardized weight based heparin protocol for the hospital for about six months.” The
barrier has been that the three cardiologists have been unable to agree a single weight
based protocol. The pharmacist informs the group that lab has had issues with
reporting of supertherapeutic PTTs because the three protocols are so different in there
therapeutic levels.
6) The group next moves to the new Pediatric floor that is not yet opened. Pediatrics
will be a new service line for Community General Hospital. The hospital is currently
evaluating equipment for the new floor and service line. The newly hired nurse
manager is very concerned with the scales that bio-engineering is looking at
purchasing. The nurse manager claims that the scales will weigh in both pounds and
kilograms and the pound function is default and cannot be locked out of the system.
The nurse manager had a serious patient event with heparin when a pediatric patient’s
weight was incorrectly entered using pounds versus kilograms. The nurse manager
would like the committees help with the issue with the scales that bio-engineering wants
to purchase for the pediatric floor.
7) The group next moves to the med/surg floor and decides follow a patient from PACU
to the floor. The patient is a post op right THA that is requires an epidural for pain
control. The group notices per the post op physician orders that Lovenox 40mg subq
daily has been ordered for VTE prophylaxis. The nurse taking care of the patient is
currently confirming the patients post op medication that pharmacy just completed
profiling. The group notices that pharmacy has added Lovenox to the patient’s profile.
The clinical pharmacist mentions that the Lovenox should have been held till after the
epidural has been discontinued. Currently neither the pharmacy system nor the nursing
system alerts that the patient is receiving an epidural and anticoagulant.
Developed by: Tennessee Pharmacist Coalition on Medication Safety, Best Practices
Sub-Committee 2014