Spotlight on Lindsay Municipal Hospital’s Adverse Drug Events-Anticoagulation project

Posted on: 2/7/2020


Each of the Excellence in Quality Award submissions will be featured in this column over the coming weeks to highlight and share successful quality initiatives. For each submission, we will describe how the problem was identified, the improvement goal(s), interventions and outcomes. Please feel free to utilize this information, duplicate interventions, and share with your staff.

Lindsay Municipal Hospital received an Honorable Mention for their Adverse Drug Events-Anticoagulation project submitted by Tandy Warren, QA/PI manager and Portia England, CNO.

Identifying the Problem: From June 2017 through February 2018, Lindsay Municipal Hospital had zero excessive anticoagulation events. However, events occurred in March and April 2018 and the facility identified this as a patient safety priority.

The Goal: The goal was to decrease anticoagulation therapy harms by 50% on a special-population medical-surgical unit by Dec. 31, 2018.

Interventions:  
  1. An Anticoagulant Team was created, which included the CMO, CNO, patient care coordinator, pharmacy manager and unity frontline staff.
  2. A bedside huddle process was implemented to address all patients on anticoagulation therapy daily on the unit. The Anticoagulation Team participated in this huddle.
  3. The AHA/HRET HIIN “Preventing Adverse Drug Events Change Package” was reviewed and criteria implemented.
  4. Automatic reflex of critical lab values through the EHR to frontline staff and patient care coordinator was implemented.
  5. Pharmacy staff monitor and trend all patients receiving anticoagulation therapy.
  6. All patients receiving anticoagulation therapy are provided education to increase self-management during their stay and upon discharge.
The Outcome: There was dramatic improvement in prevention of anticoagulation harms and the goal was met/exceeded, sustaining 11 months with zero events.

Comments: Implementation of evidence-based practice, through utilization of the AHA/HRET HIIN “Preventing Adverse Drug Events Change Package” was identified as an integral part in the success of the project. Also, the daily huddle allows for involvement from all levels: senior leadership, the direct care provider, and the front-line staff, which also promoted participation of the patient in their plan of care.