Virginia Clough

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Virginia Clough

• The Chester
• Anticoagulant Service
• Countess of
• Chester Hospital

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Coroner highlights prescribing error after a
patient dies from Warfarin overdose.BMJ 26th
October 2002
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The Chester Anticoagulant Service2002 team

• consultant haematologist - lead clinician
• clinical pharmacist ( covering colleagues)
• senior BMS 2 0.6 BMS 1
• clinical assistant 1 session
• anticoagulant nurse practitioner
• 1 part-time nurse (D) 2 part-time DVT nurses
  (F)
• 1.0 AC 3 0.5 MLA

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Problems

• Long term sickness of 1 of 2 consultants
• Clinical pharmacist ? promotion elsewhere
• Poor recruitment of pharmacy staff in the NHS
• Dosing 100 patients each afternoon

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. Administrative and clerical staff are
not amongst the staff who can have authority
delegated to them under the terms of a Patient
Group Direction..I therefore think that
admin and clerical staff carrying out a dose
variation on the basis of any group delegation of
authority would be potentially open to
prosecution under the Medicines Act.Hill
DickinsonSolicitorsMarch 2002
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Solutions

• Establish a patient group direction for nurse
  to issue and administer
• Warfarin
• Vitamin K
• Low molecular weight heparin
• Establish a document of levels of competency
  for the DAWN system

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• Q How do I know that the anticoagulant
• team are doing what I think I have
• trained them to do?
• Q How do I look at the quality of
• performance of individual dosers in
• the team?

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Chester Anticoagulant ServiceGroup Protocol

• STAGE 1 Run DAWN software with
• computer dose calculation
• Batch dose
• Print labels stick into books
• Pass to stage 2 operator for check
• Find INRs

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Chester Anticoagulant ServiceGroup Protocol

• STAGE 2 Accuracy check
• Check correct label in correct book
• Sign book
• Release to post

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Chester Anticoagulant ServiceGroup Protocol

• STAGE 3 Dose changes simple
• includes Dose changes due to fluctuation in
• INR without drug changes
• excludes New drugs or new clinical
  information
• INR lt1.3 gt5
• Cardioversion patients

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Chester Anticoagulant ServiceGroup Protocol

• STAGE 4 Dose changes complex
• includes New drugs or new clinical information
• INR lt1.3 gt5
• Immediate action for patients INR gt5
• problem patients

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Chester Anticoagulant ServiceGroup Protocol

• STAGE 5 Refer to Consultant Haematologist
• includes Review of target 3.5
• INR lt1.3 2 successive visits
• Any patient who is bleeding

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increasing competency
5 4 3 2 1
clinical problems
complex dosing
simple dosing
book checks and release
demographics
MLA AC3 BMS 1 BMS 2 CNS
Pharm Cons
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• Q How do I know that the anticoagulant
• team are doing what I think I have
• trained them to do?
• Q How do I look at the quality of
• performance of individual dosers in
• the team?

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any questions?