Minimising Medication Mishap: Introducing a Warfarin Safety Strategy

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ABSTRACTAnticoagulants have been implicated in up to 10% of all adverse drug events. In 2001, The Alfred established a Medication Safety Committee and identified warfarin therapy as a patient safety priority. Through process mapping and consultation, opportunities for error were identified throughout the warfarin prescribing, dispensing and administration processes. Clinicians considered review of prothrombin international normalised ratio results and routine warfarin dosing at 2000 hours as the most significant risk to patients. This was because warfarin was frequently prescribed by after‐hours staff who were not familiar with the patient's history or changes in their clinical condition or medication. Clinicians participated in the development and implementation of a warfarin safety strategy that involved changing the dosing to 1600 hours and alert stickers affixed to drug charts by pharmacists to identify patients prescribed warfarin. This program was effective in improving staff management of inpatients receiving warfarin. It also demonstrated the importance of an effective change management strategy in establishing a sense of urgency in clinicians regarding safety, and engagement in process analysis, risk identification and the development of simple and practical safety strategies.