289 Improving safety of patient treated by vitamin K antagonists in geriatrics

Abstract

BackgroundVitamin K antagonists (VKA) are widely used in old patients with atrial fibrillation or venous thromboembolism. Safety is a major concern, especially in old patients. International normalised ratio (INR)>5 is associated with an increased risk of bleeding and is considered as a near miss error.AimTo reduce the incidence of episodes of INR>5 which occurred during the hospital stay of patients of a geriatric hospital ward exposed to VKA. Design: Intervention study, non randomised.MethodsThe study was done in five geriatric wards comprising acute, intermediate and long-term care beds of a French hospital. The intervention was conducted in one ward of the hospital. A structured teamwork among the medical staff of the geriatric ward was implemented from July to December, 2005. Twice monthly, the medical staff examined during a short meeting the cases of all the patients with INR>5 which occurred during the preceding weeks. The group discussed cases using a tool designed to identify prescribing errors in dose adjustment and/or INR monitoring. The approach was proactive in order to learn from errors and not punitive. The number of patients exposed to VKA and the number of episodes of INR>5 were recorded during a 12-month period before the intervention (2004–2005) and during the year following it in the intervention ward and in control wards (2006).ResultsIn control wards, 60 episodes of INR>5 were recorded in the 267 patients (22.5%) receiving VKA in 2004–2005 and 56 episodes among the 263 (22.1%) in 2006. In the intervention ward, 22 episodes were recorded in the 72 patients (30.6%) in 2004-2005, and 16 episodes of INR>5 were recorded among the 92 patients (17.4%), corresponding to a significant decrease (−43.1%) as compared to control wards (–1.8%, p<10–4).ConclusionA structured teamwork focused on cases of INR>5 lessen the risk of VKA overdosage and might improve safety of anticoagulation. Learning from errors seems an efficient way to improve quality of care.ContexteLes antivitamines K (AVK) sont largement utilisées chez les patients âgés ayant une fibrillation auriculaire ou une maladie veineuse thromboembolique. La sécurité est une préoccupation majeure, en particulier chez les patients âgés. L'international normalised ratio (INR)>5 est associé à une majoration du risque de saignement et est considéré comme un événement critique.ButRéduire l'incidence des épisodes d'INR>5 survenant pendant le séjour hospitalier chez les patient d'un service de gériatrie recevant des AVK.Type d'étudeInterventionnelle non randomisée.MéthodesL'étude a été conduite dans 5 services hospitaliers de gériatrie comprenant des lits de court séjour, de soins de suite-réadaptation et soins de longue durée. L'intervention a été conduite dans un service de l'hôpital. Un travail structuré au sein de l'équipe médicale a été conduit de juillet à décembre 2005. Deux fois par mois, l'équipe médicale a examiné durant une courte réunion tous les épisodes d'INR>5 au cours des semaines précédentes. Le groupe a discuté les cas en utilisant un out...