BackgroundScant literature exists evaluating utilization patterns for direct oral anticoagulants (DOACs).ObjectivesThe primary objective was to assess DOAC prescribing in patients with venous thromboembolism (VTE) and nonvalvular atrial fibrillation (NVAF) in outpatient clinics. Secondary objectives were to compare utilization between family medicine (FM) and internal medicine (IM) clinics, characterize potentially inappropriate use, and identify factors associated with adverse events (AEs).MethodsThis was a retrospective cohort study of adults with NVAF or VTE who received a DOAC at FM or IM clinics between 10/19/2010 and 10/23/2014. Descriptive statistics were utilized for the primary aim. Fisher’s exact test was used to evaluate differences in prescribing using an adapted medication appropriateness index. Logistic regression evaluated factors associated with inappropriate use and AEs.ResultsOne-hundred twenty patients were evaluated. At least 1 inappropriate criterion was met in 72 patients (60.0%). The most frequent inappropriate criteria were dosage (33.0%), duration of therapy (18.4%), and correct administration (18.0%). Apixaban was dosed inappropriately most frequently. There was no difference in dosing appropriateness between FM and IM clinics. The odds of inappropriate choice were lower with apixaban compared to other DOACs (odds ratio [OR]=0.088; 95% confidence interval [CI] 0.008–0.964; p=0.047). Twenty-seven patients (22.5%) experienced an AE while on a DOAC, and the odds of bleeding doubled with each inappropriate criterion met (OR=1.949; 95% CI 1.190–3.190; p=0.008).ConclusionPotentially inappropriate prescribing of DOACs is frequent with the most common errors being dosing, administration, and duration of therapy. These results underscore the importance of prescriber education regarding the appropriate use and management of DOACs.

Phytonadione (vitamin K1, VK) is fat soluble and may be sequestered by adipose tissue, thus potentially altering drug distribution in obese patients requiring warfarin reversal. This single-center retrospective cohort study aimed to determine the effects of obesity (defined as body mass index [BMI] ≥ 30 kg/m 2 ) on warfarin reversal following administration of VK in adult patients. The primary outcome was complete or partial warfarin reversal (defined as an international normalized ratio [INR] ≤ 2.0) within 72 hours post-VK administration. Of 688 identified patients, 215 were included in primary INR analysis. Mean BMIs for obese (n = 84) and nonobese (n = 131) patients were 37.3 and 24.3 kg/m 2 ( P < .001), and mean baseline INRs were 4.73 and 4.42 ( P = .534), respectively. Within 72 hours post-VK administration, 70% and 69% of the obese and nonobese groups, respectively, achieved complete or partial warfarin reversal ( P = .904). Multiple logistic regression determined baseline INR and concomitant fresh frozen plasma administration to be factors influencing warfarin reversal. These findings do not suggest obesity is significantly associated with a decreased likelihood of warfarin reversal within 72 hours post-VK administration.

Universal Health Services experienced a cyberattack in September 2020 that impacted all hospitals in their system. Nearly all computer systems that store and communicate patient care information were shut down to prevent malware propagation. The impact of this attack was magnified by the ongoing coronavirus disease 2019 (COVID‐19) pandemic. The objective of this paper is to describe the response of our intensive care unit (ICU) rounding team to the loss of all electronic health record (EHR) systems within our institution and to share lessons learned through the experience. Guidance is available on prevention of cyberattacks but does not effectively address the need to establish and train providers for alternative care mechanisms at the local level. Many providers and trainees have limited or no experience with manual patient care systems and had difficulty in transitioning to paper records, notes, and order writing. The transition also highlighted a number of unintended consequences that have occurred secondary to implementation and adaptation of EHRs over time. Institutional memory played a major role in addressing the crisis as providers who had utilized paper charting systems were more adaptive. Critical care pharmacists practicing as members of an integrated ICU health care team were an essential resource during the crisis, maintaining patient safety, assisting with order writing, troubleshooting medication issues, and providing education. The cyberattack provided an opportunity to re‐evaluate processes and procedures that have developed over time through the use of EHRs. The crisis magnified the importance of team‐based care and the integral role of the acute care clinical pharmacist.