Safe and Effective Digital Anticoagulation: A Continuous Iterative Improvement Approach

Abstract

Background Anticoagulant drugs are the leading cause of medication harm in hospitals and prescribing errors are common with traditional paper prescriptions. Electronic medicines management can reduce prescribing errors for many drugs; however, little is known about the impact of e-prescribing on anticoagulants. Our case study reports on the lessons learned during conversion from paper to e-prescribing and the ongoing optimization process. Methods The iterative implementation of an anticoagulant prescribing platform in an integrated electronic medical record (ieMR) and ongoing continuous enhancements was applied across five digital hospital sites utilizing a single domain. The collaborative management of each class of anticoagulant, optimization strategies, governance structures, and lessons learned is described. An analysis of the rate of errors and adverse events pre- and post-go live is presented. Results The transition to e-prescribing relied on a strong inter-disciplinary governance framework to promote the safe management of anticoagulants. There was no increase in overall prescribing errors, however unfamiliarity with the new system caused a transient increase in errors with unfractionated heparin (1.8/month pre-ieMR vs. 5.5/month post-ieMR). A dedicated real-time surveillance dashboard was introduced. The iterative nature of changes indicated the complexities involved with anticoagulants and the need for an interactive, optimization approach. This led to a significant decrease in anticoagulant related hospital acquired complications (12.1/month pre-ieMR vs. 7.8/month post-ieMR, p = 0.01). Conclusion Digitizing anticoagulant prescribing led to an overall reduction in errors, but a continuous iterative optimization approach was needed to achieve this outcome. The knowledge presented can help inform optimal therapeutic anticoagulation ieMR design strategies.

The Effect of Digitization on the Safe Management of Anticoagulants

“…(32) We have previously reported on the key design features locally employed to digitally manage therapeutic anticoagulation. (23) The current study offers evidence that digitisation reduces bleeds associated with anticoagulant use and HIT cases, and some insight into potential areas for improvement in system design as digital transformation continues to evolve. (33) Given the constraints of an observational pre/post study design, the intent is not to link causality with EMR implementation, but to highlight areas of association.…”

“…Subsequent system design changes have since been made to alert users to doses that exceed 40 to 45 units/kg/h. 23 …”

“…We have reported previously on the local strategies employed and lessons learned to manage therapeutic anticoagulation on a digital platform. (23) This study seeks to assess the impact of EMR implementation on the quality and safety of anticoagulation management.…”

“…Subsequent system design changes have since been made to alert users to doses that exceed 40 to 45 units/kg/h. 23 Inappropriate drug combinations were the most cited clinical error type. In all cases, drug interaction alerts fired and were overridden, consistent with previously published data suggesting that up to 96% of alerts are overridden.…”