HANYS’
2010 Pinnacle Award for Quality and Patient Safety
Submission Template and Guidelines
Section I:
A. Contact information required for publication and feedback.
Required Information
Please type in white space only.
Complete below:
Full Name
Abdul Mondul MD
Credentials
Title
Assistant Professor of Clinical Medicine
Weill Medical College at Cornell University
Organization Name
Patient Safety Officer
Associate Chair Department of Medicine
Organization
Address
Lincoln Medical and Mental Health Center
234 East 149th Street
Bronx, New York 10451
Telephone
E-mail
718-579-5280
Abdul.Mondul@nychhc.org
B. Check applicable submission category:
[ ] System or multi-level entity
[X] Large Hospital (> 100 mean daily patient census)
[ ] Small Hospital or Outpatient Organization
[ ] Division, Specialty, or Unit-based entity
C. Check if you are a Nassau-Suffolk Hospital Council (NSHC) member and would like this entry to also
be submitted for the NSHC Annual Quality Award.
[ ] Yes
Section II: See brochure for directions. This project narrative section should be (1) written and reviewed
for potential publication, (2) must not include any facility-identifying information for the judges’ review, and
(3) cannot exceed this one page format using just the white space section, single spaced, and11 pt. Times
New Roman.
Information Required
Please Complete in This Column
Name of Initiative
This section is between 25 and 30 words.
Project Description
(Narrative Summary)
This section is between 150 and 225
words, depending on use of space and
bullets.
Improving Anticoagulation Safety Through a Hospital Wide,
Interdisciplinary Approach
Anticoagulants are high-risk, high-alert and high-value
medications. Management of these drugs is a complex and
challenging task for health care systems. These live saving
medications are used to treat and prevent arterial and venous
thrombo-embolism; however they are also frequently associated
with medication errors.
A systematic interdisciplinary review of our anticoagulation
practices was conducted, opportunities for improvement were
identified and specific indicators to measure process and outcomes
were developed. Methods used included failure mode effects
analysis, GAP analysis, literature review, expert team meetings and
data collected prior to program implementation.
Based on the findings a hospital wide anticoagulation program was
implemented with strategies to improve the safe use of Warfarin,
Low molecular weight Heparin and un-fractionated heparin. An
anticoagulation manual was developed to facilitate hospital wide
education and competency evaluation. An electronic order set
embedded within the CPOE (computerized physician order entry)
was implemented to provide additional clinical decision support.
A patient registry was created for patients on anticoagulation that
follow in our ambulatory care clinic and system changes were
implemented on the tracking, recall and visit structure for them.
Point of care testing for INR was also adopted.
There is ongoing monitoring of the indicators and these are shared
in several hospital committees. A New York State DOH Empire
Clinical research investigator program (ECRIP) scholarship that
will focus on anticoagulation was applied for and granted.
Outcomes Achieved
 Please use bullets
 A one-page Word document can
also be submitted containing
one or more graphics.
This section is approximately 60 words
when using bullets.
Lessons Learned
 Top three lessons
utilizing bullets.

The number of patients within therapeutic INR in our
ambulatory care clinic increased from 50% to 83 %
(Literature reference 55 -60%)

Compliance with weight based dosing of Unfractionated
heparin initial bolus improved from 73% to 100% and for
maintenance from 80% to 95%

Compliance with weight based dosing of Low molecular
weight heparin in the inpatient services increased from
80% to 95 %

Compliance with protocol defined transition from
Unfractionated heparin or Low molecular weight heparin
to warfarin increased to 95% (Literature search reference
50%)

Education by dietitian of patients on Warfarin in the
inpatient units increased from 69% to 97%

Unmonitored dose reduction of Warfarin
(When the dose of Warfarin is reduced and an INR is not
repeated prior to resuming therapy) decreased to zero

Implementing a comprehensive anticoagulation program
requires interdisciplinary commitment, collaboration and
ongoing education

Developing process and outcomes measures is important to
address successes and opportunities for improvement

Our hospital is performing better than the available
published data on multiple anticoagulation indicators and
significant improvement was achieved through this
program
learned
This section is approximately 45 words
when using bullets.
Section III: Additional supporting information cannot exceed two pages. Please do not include identifying
information for judges’ review.
Information
Required
Problem
Statement
Please Complete in This Column
Anticoagulants are life-saving drugs used to treat and prevent arterial and venous
thrombo-embolism; however they are also a high-risk high-alert category of drugs that
are frequently associated with medication errors
The Institute for Safe Medication Practices (ISMP) and the Institute for Healthcare
Improvement (IHI) emphasize the importance of a comprehensive anticoagulation
program and in 2008 The Joint Commission issued NPSG 3E that aims to reduce the
likelihood of harm associated with the use of anticoagulants.
In patients taking warfarin, maintaining an INR within the therapeutic range is difficult.
Patients within a clinical trial setting had therapeutic INR’s only 60% of the time and a
recent review revealed that clinic patients who receive long-term Warfarin achieve
therapeutic INR’s only 55% of the time. Having INR’s out of therapeutic range 10% of
the time is associated with an increased risk of mortality, ischemic stroke and other
thromboembolic events among those receiving long- term Warfarin for non-valvular atrial
fibrillation. Warfarin is commonly associated with adverse events, mainly bleeding due to
its narrow therapeutic window (i.e., it is easy to over or under dose), the complexity of
dosing and monitoring, patient compliance, numerous drug interactions, and dietary
interactions.
Errors related to Unfractionated heparin accounts for majority (66.2%) of errors or 1.67
medication errors for every 1,000 patients receiving anticoagulation therapy (Franikos, et.
al, 2004). 6.2% patients that were exposed to anticoagulant medication error required
some type of medical intervention, while 1.5% required prolonged hospitalization.
Strict compliance with Weight based dosing of unfractionated heparin and low molecular
weight heparin, protocol guided transition to warfarin and protocol guided chronic
warfarin therapy reduces the risk for adverse outcomes.
Aim-Goals



Methodologies
and Change
Principles








Standardize and implement best practices in the prescribing, administering and
monitoring processes in the use of un-fractionated heparin, low-molecular weight
heparins and Warfarin
Ensure effective education, interaction, and collaboration among care providers
and patients to achieve therapeutic levels of anticoagulants and maintain safety
during use
Develop Indicators to measure effectiveness of the anticoagulation program
Baseline evaluation of anticoagulation practices by the Pharmacy & therapeutics
and Drug utilization – Evaluation committees (2006 - 2007)
Formed a multidisciplinary anticoagulation practices committee (2007)
Incorporated dosing guidelines as a Clinical decision tool in the EMR (2007)
Failure mode effects analysis on anticoagulants conducted ( 2007)
GAP analysis and implementation of 20 best practices recommended by ISMPIHI (2007)
Developed a system to generate a daily list of all Inpatients on anticoagulation for
referral to dietitian (2007)
Compiled a comprehensive Anticoagulation manual reflecting best practices for
clinicians (2008). This manual was rolled out to other hospitals in our corporation
(2009)
Developed Patient education tool and translated into Spanish (2008); the
educational tool was then translated into the top 12 languages of our patients
(2009)





Additional
Outcomes Not
Listed in Section II


Sustainability
Strategies

Educated all clinical staff on safe anticoagulation practices with specific elements
and competencies ( Pharmacy, Nursing, Nutrition, Physicians) (2008)
Implemented an electronic order embedded within the CPOE (computerized
physician order entry) (2008)
Created a patient registry and recall system for patients on anticoagulation in the
ambulatory care and INR point of care testing (2008)
100% review of the records of patients that receive therapeutic heparin (both Unfractionated and low molecular weight)
Developed Multiple Performance improvement projects to measure and share
success
One of the achievements of this project was increased staff knowledge and
understanding of their significant role in the dosing, monitoring and patient
education as it relates to anticoagulation therapy. Residents, nurses, pharmacists
and dieticians know the risks and benefits of anticoagulation therapy.
The use of an outpatient registry to track, recall and a streamlined visit structure
for anti-coagulated patients contributed to an excellent rate of therapeutic INR in
the out patient setting
Continuous monitoring of indicators and reporting to the Drug utilization /
evaluation committee and the hospital wide performance improvement committee

Pharmacy concurrent monitoring of anticoagulation practices. All deviations from
protocols are reported to the patient safety officer who in turn provides feedback
to the chiefs of services and providers

Hospital wide anticoagulation education with yearly competency assessment
specific to clinical discipline

Integration of performance improvement with research through the New York
State DOH Empire Clinical research investigator program (ECRIP) scholarship

Business Case
Information
Conclusion,
Recommendation
s, or Next Steps
Celebrating success: for example the pharmacists involved in the project were
acknowledged as patient safety champions during National Patient Safety Week,
March 2010
It is known that 1.5 million preventable adverse drug events (ADE’s) occur in the United
States each year, over 770,000 people are injured or die each year in hospitals from
ADE’s at an annual cost up to $5.6 million per hospital and total cost to US $5.6 billion
annually. Warfarin and insulins caused: one in every seven ADE’s treated in emergency
departments and more than a quarter of all estimated hospitalizations. In the elderly,
insulin, warfarin, and digoxin were implicated in one in three estimated ADR’s treated in
the emergency departments and 41.5% of estimated hospitalizations. Patients that were
exposed to anticoagulant medication error from unfractionated heparin required some type
of medical intervention and prolonged hospitalization.
The implementation of a comprehensive anticoagulation program reduces costs related to
treatment, readmission or prolonged hospital stay related to ADR’s.
 It is important to utilize a multi-disciplinary approach to improve the safe use of
high alert medications by implementing best practices, adopting performance
indicators and developing educational tools for providers and patients

Excellent compliance with protocol guided anticoagulation practices is achievable

Going forward, we will continue to monitor performance, ongoing clinical staff
education, share our processes with other hospitals in our corporation and publish
our data with the support of the ECRIP research fellow.
A. Patients with Therapeutic INR in Ambulatory Care
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
B. Low Molecular Weight Heparin Dosing
100%
80%
60%
40%
20%
Published
Reference
1st Qtr
2007
11
/0
8
2
11
/08 007
(
n
12
=1
/08
3)
(n=
1/0
15
)
9(
n=
2/0
12
)
9(
n=
3/0 1 4)
9
4/0 (n=9
)
9(
n
5/0 =1 0
)
9
(n
6/0 =4 )
9(
n
7/0 =9 )
9(n
8/0 =4)
9(n
9/0 =8)
9(n
10
/09 =8)
(n=
1
11
/09 5)
(n=
12
/09 6 )
(n=
8)
100
90
80
70
60
50
40
30
20
10
0
F. Dosing of Un-fractionated Heparin Infusion
100
90
80
70
60
50
40
30
20
10
0
11
/0 200
8
7
12 (n
/0 = 1
8
5)
1/ (n=
09 16
)
2/ (n=
09 1 5
(n )
3/ =1
09 5
)
4/ (n
09 =9
(n )
5/ =1
09 0)
6/ (n=
09 7 )
(
7/ n=9
09
)
(
8/ n=6
09 )
9/ (n=
09 9
)
10 (n=
/0 11
9(
)
11 n=1
/0
7)
12 9 (n
/0 =8
9(
n= )
11
)
E. Dosing of Un-fractionated Heparin Bolus
4th Qtr
2009
=4
)
11
/0
9(
n=
4)
4th Qtr
2009
=2
)
3rd Qtr
2009
=4
)
2nd Qtr
2009
(n
1st Qtr
2009
3rd Qtr
2009
9/
09
(n
Published
Reference
4th Qtr
2008
2nd Qtr
2009
100
90
80
70
60
50
40
30
20
10
0
3)
40%
3rd Qtr
2008
1st Qtr
2009
7/
09
(n
60%
2nd Qtr
2008
4th Qtr
2008
(n
=
80%
0%
3rd Qtr
2008
D. Appropriate Transition from Un-fractionated Heparin to
LMWH / Warfarin
100%
20%
2nd Qtr
2008
3)
C. Low Molecular Weight Heparin Transition to Warfarin
1st Qtr
2007
0%
Nov09
5/
09
Sep09
(n
=
Jul09
4)
May.
09
3/
09
Mar.
09
(n
=
Jan.
09
1/
09
Nov.
08
G. Inpatients on Warfarin - Education by Dietitian
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Sept. 08 4th Qtr
2008
1st Qtr 2nd Qtr 3rd Qtr
2009
2009
2009
H. INR Availability at Follow up Appointment
4th Qtr
2009
A one-page Word document containing one or more graphics can also be submitted.