An adverse event occurred at Boston Children’s Hospital involving anticoagulation workflows. This event led to a nurse-driven initiative to evaluate the current processes for patients on anticoagulation therapy.
On the basis of this evaluation, the following were identified as steps or practices during which adverse events could occur: anticoagulation ordering and prescribing, understanding of the treatment plan on the part of nurses and patients, and outpatient follow-up. This interactive learning session will present the interventions that were implemented at our institution: (1) the enoxaparin order set was revised to discern treatment dosing versus prophylactic dosing; (2) an electronic medical record nursing anticoagulation discharge plan was created to ensure a safe anticoagulation discharge; (3) outpatient calls were initiated by the thrombosis and anticoagulation program nurses to the patient or family within 24 hours of discharge to evaluate and reinforce education; (4) an enoxaparin safety checklist was created to guide the patient care process from admission to discharge; (5) a family education sheet was developed to provide consistent information necessary for patients receiving anticoagulation medication. These tools can be used as a framework for change to mitigate similar adverse events and human errors in healthcare systems nationwide.
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