REDUCE THE LIKELIHOOD OF PATIENT HARM ASSOCIATED WITH THE USE OF ANTICOAGULANT THERAPY

1. Module 3 REDUCE THE LIKELIHOOD OF PATIENT HARM ASSOCIATED WITH THE USE OF ANTICOAGULANT THERAPY

2. ONLY oral unit-dose warfarin, prefilled Fragmin syringes, and premixed heparin drips are used at CHSB.

3. Use Approved Protocols • CHSB Inpatient Anticoagulation Protocol • Available on all units in the Pharmacy Protocol/Formulary Book • Includes warfarin (Coumadin), heparin and LMWH (Fragmin) • Defines roles of RPh, RN, and Dietician

4. Warfarin • Pharmacy-dosed protocol • Rx will monitor and dose all patients • MUST check/document INR before 1st dose • Rx will not dispense doses until INR available • RN must document INR on eMAR prior to each dose • Care Plan must be initiated & updated • Monitor patient for bleeding • Check INR • Educate patient re: bleeding, safety precautions • Education must be documented during admission and at discharge

5. Warfarin Vitamin K reverses the effects of warfarin • Food-Drug Interactions • Vitamin K in foods • Green, leafy vegetables • spinach, collard greens, brussel sprouts, broccoli • Cranberry juice • Discharge Instructions • Krames On Demand • MUST include: • Compliance and the importance of follow-up monitoring • Food-Drug Interactions • Potential for adverse drug reactions and interactions

6. Heparin • NPSG includes therapeutic heparin • Heparin flushes, prophylactic doses excluded • MUST use premade heparin drips • Do NOT mix a heparin drip • MUST use the drug library on the infusion pumps when administering

7. Heparin Protocol • Bolus Doses – use 1000 units/ml ONLY • NEVER bolus from the infusion bag! • Weight-based dosing • Monitoring • aPTT • baseline • every 6 hours after ANY dosage change • 6 hours after first therapeutic aPTT • every 24 hours after 2 consecutive aPTTs • CBC with platelets • Baseline • every 3 days

8. Heparin Protocol • Adjusting the rate: • aPTT <60: bolus dose and ↑ rate • aPTT 60-90: NO ADJUSTMENT • aPTT >90: hold drip and/or ↓ rate • Recheck the aPTT in 6 hours • Document all bolus doses and rate changes on eMAR • Each bolus dose is documented on eMAR • Any rate changes and each bag change are document on eMAR

9. Low-Molecular Weight Heparin(Fragmin) NPSG includes therapeutic doses Low-dose for DVT prophylaxis excluded Baseline labs required CBC with platelets

10. Pradaxa(dabigatran) • Baseline laboratory tests: • PT/INR • SCr • Ongoing laboratory tests: • SCr every 7 days • Pharmacy will adjust dose as needed for renal function

11. Xarelto(RIVAROXABAN) • Baseline laboratory tests: • CBC • SCr • Ongoing laboratory tests: • SCr every 7 days • Should be avoided in patients on dialysis • Medication should not be crushed • Give with food for better absorption

12. Patient Education • Only Krames On-Demand will be used • Coumadin (warfarin) • Heparin • Fragmin • Pradaxa • Xarelto