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28 Development of a systematic approach to reduce the likelihood of patient harm associated with anticoagulant therapy
  1. R Jedeikin,
  2. K Rutt,
  3. S Trujillo,
  4. T Preston,
  5. S Olson
  1. Phoenix Children’s Hospital Coumadin Clinic



  • Coumadin identified by Institute for Safe Medication Practice as high–risk medication with narrow therapeutic window and high risk of life threatening adverse effects

  • Anticoagulants identified as one of the top five drug types associated with patient safety incidents

  • Maintaining INR in recommended therapeutic ranges reducing the incidence of adverse effects

  • Improve INR–TTR(time in therapeutic range) in patients managed through the Coumadin Clinic

  • Comply with nationally established INR goal guidelines


  • Develop routine order sets

  • Define team roles/expectations

  • Develop point–of–care resource optimising access to INR testing.

  • Educational program targeting stakeholders

  • Monthly meeting auditing patients with goal analysis utilising tracking tools

  • Review of process/outcome measures.

  • Intervene for change utilising PDSA methodology

  • PDSA Cycle 1:

    • Retrospective data collection–2008

    • No systematic approach in place/data regarding patient TTR not available

    • No structured staff/patient education program

  • PDSA Cycle 2:

    • Implement changes

    • Web–based software purchased

    • Structured approach to INR management implemented including stakeholder education program

  • PDSA Cycle 3:

    • Problem monitoring/notifying overdue INR patients

    • Team member roles/responsibilities redefined

    • ‘Buddy system’ implemented to monitor/notify overdue patients


  • TTR increased from 66%-2008 to 79%-2013 following implementation of structured policies/programs

  • Re–implementation of education program, revision of policy/procedures TTR increased to 80% Jan–May–2015

  • Optimized point–of–care for INR testing–office finger–stick/remote laboratory testing/home monitoring

  • Increased INR home monitoring


  • With development of systematic approach to high risk patients on anticoagulation therapy, using a web–based software program, significant changes were evident:

  • Improved patient follow–up, communication, decrease in overdue patient numbers

  • Increased percentage of patients’ within INR range

  • Approach driven by the PDSA CQI methodology

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