Virginia Clough The Chester Anticoagulant Service Countess of Chester Hospital

Virginia CloughVirginia Clough

The Chester Anticoagulant Service

Countess of Chester Hospital

“Coroner highlights prescribing error after a patient dies from Warfarin overdose”.

BMJ 26th October 2002

The Chester Anticoagulant Service

2002 team

consultant haematologist - lead clinicianclinical pharmacist (& covering colleagues)senior BMS 2 0.6 BMS 1clinical assistant 1 sessionanticoagulant nurse practitioner1 part-time nurse (D) 2 part-time DVT

nurses (F)1.0 AC 3 0.5 MLA

ProblemsProblems

Long term sickness of 1 of 2 consultants

Clinical pharmacist → promotion elsewhere

Poor recruitment of pharmacy staff in the NHS

Dosing 100+ patients each afternoon

“………. Administrative and clerical staff are not amongst the staff who can have authority delegated to them under the terms of a Patient Group Direction”.

“……….I therefore think that admin and clerical staff carrying out a dose variation on the basis of any group delegation of authority would be potentially open to prosecution under the Medicines Act”.

Hill DickinsonSolicitorsMarch 2002

∙ Establish a “patient group direction” for nurse to issue and administer:

WarfarinVitamin KLow molecular weight

heparin∙ Establish a document of “levels of

competency” for the DAWN system

SolutionsSolutions

Q: How do I know that the anticoagulantteam are doing what I think I have

trained them to do?

Q: How do I look at the quality ofperformance of individual “dosers” inthe team?

Chester Anticoagulant Service

Group Protocol

STAGE 1 Run DAWN software withcomputer dose calculationBatch dosePrint labels & stick into booksPass to stage 2 operator for checkFind INR’s

Chester Anticoagulant Service

Group Protocol

STAGE 2 Accuracy checkCheck correct label in

correct bookSign bookRelease to post

Chester Anticoagulant Service

Group ProtocolSTAGE 3 Dose changes : simple

includes Dose changes due to fluctuation in INR without drug changes

excludes New drugs or new clinical information

INR <1.3 >5Cardioversion patients

Chester Anticoagulant Service

Group ProtocolSTAGE 4 Dose changes : complex

includes New drugs or new clinical information

INR <1.3 >5Immediate action for patients INR

>5“problem” patients

Chester Anticoagulant Service

Group Protocol

STAGE 5 Refer to Consultant Haematologist

includes Review of target 3.5INR <1.3 2 successive visitsAny patient who is bleeding

MLA AC3 BMS 1 BMS 2 CNS Pharm Cons

increasingcompetency

5

4

3

2

1 demographics

book checks and release

simple dosing

complex dosing

clinical problems

Named personnel and dosing level competency

All DAWN team members have a designated dosing competency level.

All new members will be assigned a dosing competency level after appropriatetraining and authorisation by a named member of staff.

Anticoagulant Team Members

Dosing level Position Name

1 MLA Nicola Dunn2 Administrative Assistant Barbara Long3 BMS 1 Anticoagulation Julie Hargreaves3 BMS 2 Anticoagulation Elaine Norris3 Anticoagulant Nurse Diane Gittins4 Clinical Pharmacist Alistair Jones4 A/C Nurse Practitioner Lucy Langan4 Clinical Assistant Dr R Philp5 Consultant Haematologist Dr V Clough

Q: How do I know that the anticoagulantteam are doing what I think I have

trained them to do?

Q: How do I look at the quality ofperformance of individual “dosers” inthe team?

any questions?