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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?
