Community Pharmacy Safety in Practice Warfarin Change Package Pharmacy Safety in Practice Warfarin Change Package 2017 . 2 ... Community Pharmacy Safety in Practice ... On reviewing the patient records, ...

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<ul><li><p>1 This document has been developed based on the Scottish Patient Safety Programme </p><p>Community Pharmacy Safety in Practice </p><p>Warfarin Change Package 2017 </p></li><li><p>2 This document has been developed based on the Scottish Patient Safety Programme </p><p>Community Pharmacy Safety in Practice </p><p>Community Pharmacy Safety in Practice 2017/2018 is a pilot programme. We want to make it suit </p><p>your needs. We welcome your feedback regarding the programme, learning sessions, ease of use of </p><p>the materials and resources, and what can be improved for the programme going forward. </p><p>Please send questions or feedback regarding Safety in Practice to Sarah Young, </p><p>Sarah.Young2@Waitematadhb.govt.nz, mobile 021 537 346, phone 09 486 8920 x 3742. </p><p>Warfarin Change Package </p><p> Background A key aim of the Safety in Practice programme is to reduce the harm experienced by patients from </p><p>medication use. Adverse drug events (ADEs) and adverse drug reactions are major causes of patient </p><p>morbidity and mortality, and a source of significant costs for both organisations and patients1. </p><p>In a journal article from NZMJ this year, Medication-related patient harm in New Zealand hospitals, </p><p>warfarin was noted to be the top 10 medicine causing harm, predominantly due to bleeding. </p><p>Warfarin was attributed to 1.8% of harm documented in this study1. </p><p>Based on exploratory analysis into administrative data for 9,000 local hospital admissions, 9% of all </p><p>potential adverse drug events (ADE) detected were anticoagulant related 2. </p><p>This change package focuses on the safe use of warfarin, for example: </p><p>o Effective patient education o Ensuring patient understanding of alarm symptoms to report to a healthcare professional o Consistent documentation of patient education and interventions to evidence work </p><p>conducted </p><p>mailto:Sarah.Young2@Waitematadhb.govt.nz</p></li><li><p>3 This document has been developed based on the Scottish Patient Safety Programme </p><p>NSAID Change Package Aim </p><p>Aim: All patients prescribed warfarin will receive appropriate warfarin education on collection of their warfarin. </p><p>Measuring Reliability of Your Care Pharmacist Scope of Practice5 </p><p>The practice of pharmacy is necessarily broad and is wider than pharmacists working directly with </p><p>patients, given that such roles influence clinical practice and public safety. In a clinical role, the </p><p>pharmacist acts as a medicines manager, providing patient-centred medication therapy </p><p>management, health improvement and disease prevention services, usually in a collaborative </p><p>environment. Pharmacists ensure safe and quality use of medicines and optimise health outcomes </p><p>by contributing to patient assessment and to the selection, prescribing, monitoring and evaluation of </p><p>medicine therapy5. </p><p>Good medicines management and patient education are core responsibilities of pharmacists, and in </p><p>conjunction with a Pharmacy Expert Group, we have developed process and patient outcome </p><p>measures that we believe represent best practice for warfarin management and education, in a </p><p>succinct manner. </p><p>These measures indicate expectations of best practice for every patient, every time, for those </p><p>taking warfarin. </p><p>It is important and best practice to document all interventions and recommendations made to </p><p>evidence work that has been carried out. This is one way pharmacists can show all the work that </p><p>they do, in line with Pharmacy Council of New Zealand Competence Standard O1.4.7. Therefore, the </p><p>process measures relate to documented evidence that the best practice activities have been </p><p>performed. </p><p>Competence Standard O1.4.7 Supports and provides continuity of care with accurate and timely documentation of clinical and </p><p>professional interventions and recommendations, using agreed handover protocols. </p></li><li><p>4 This document has been developed based on the Scottish Patient Safety Programme </p><p>Process and Patient Outcome Measures The process measure questions assess whether there is documented evidence of the measures. The patient outcome measure questions assess whether the patient has understood and can recall the information provided. These questions relate to the patient or carer as applicable. Please see Table 1: Measures and Rationale below for further guidance regarding these measures. </p><p> Part 1: Warfarin Process Measures Questions 1 5 relate to whether there is documented evidence of the following activities. Question 6 is a review of questions 1 5. </p><p>1. Does the patient know their target INR and current warfarin dose? </p><p>2. Has the patient been informed how to take their warfarin and what to do if they miss a warfarin dose? </p><p>3. Has the patient been informed about potential side effects and what to report? 4. Has the patient been informed about warfarin interactions with medicines (prescription, OTC </p><p>and complementary), supplements, and the effects of food and alcohol? 5. Has the patient been offered written warfarin information? 6. Have all the measures been met? </p><p> Part 2: Warfarin Patient Outcome Measures Questions 7 10 are patient questions to assess patient outcomes via follow up eg phone call. </p><p> 7. Could the patient appropriately tell you when to take warfarin? </p><p> 8. Could the patient appropriately tell you what they would do if they miss a dose of warfarin? 9. Could the patient identify at least one of the common side effects of warfarin? 10. Could the patient identify at least one appropriate person to ask for help about their </p><p>medicines or side effects? </p></li><li><p>5 This document has been developed based on the Scottish Patient Safety Programme </p><p>Data Collection Instructions </p><p>In order to assess your processes for warfarin management and patient education, we require data </p><p>from 10 patients taking warfarin to be collected every month. </p><p>Note: We DO NOT require NHI or patient identifiable data, so please ensure it is anonymous. </p><p> Data Collection Steps Please refer to the Toniq or LOTS screenshots in the appendix, for more guidance in selecting patients. </p><p> 1. Identify all patients who were dispensed warfarin in the previous calendar month. </p><p>2. Randomly select 10 patients from the identified list. </p><p>3. On reviewing the patient records, complete the data collection table for compliance with the </p><p>measures. Documented evidence is required for questions 1-5. Questions 7-9 are patient </p><p>outcome measures and require patient follow up eg by phone call. If you are unable to locate a </p><p>patient phone number for one of the 10 sample patients, please note this in the data collection </p><p>spreadsheet. </p><p>4. Complete the data collection sheet and submit to sarah.young2@waitematadhb.govt.nz by the </p><p>15th of the month. </p><p>5. Discuss the results as a team and look for opportunities for improvement. </p><p>6. Plan and test change(s) using PDSA cycles. </p><p>7. Repeat data collection and submission process each month. </p><p> Please note: we expect low scores for the baseline September 2017 data, where interventions occurred prior to the Safety in Practice programme beginning, so do not worry. </p><p>mailto:sarah.young2@waitematadhb.govt.nz</p></li><li><p>6 This document has been developed based on the Scottish Patient Safety Programme </p><p>Table 1: Measures and Rationale Please note: these questions relate to the patient or carer as applicable. </p><p># Measure Rationale </p><p>1. Does the patient know their target INR and current warfarin dose? </p><p>Yes No </p><p>There is good evidence that improved patient knowledge and understanding of the use of warfarin improves anticoagulation control. 3,4,5 If the patient does not know their target INR, and this information is not documented on testsafe or a recent clinical letter or EDS, you could recommend that your patient discusses with their GP Nurse. </p><p>2. Has the patient been informed when and how to take their warfarin and what to do if they miss a warfarin dose? </p><p>Yes No </p><p>Refer to Warfarin Red Book page 28 or other suitable source. </p><p>Warfarin Treatment Booklet "Red Book" available free from Medidata, phone (09) 488-4272. </p><p>3. Has the patient been informed about potential side effects and what to report? </p><p>Yes No </p><p>Bleeding can occur when the INR is between 2 and 3, but is more likely with higher INRs. Some medicines and supplements can increase bleeding risk without increasing INR. </p><p>Tell the patient about the following symptoms to report immediately to a health care professional: </p><p> Red or brown urine </p><p> Red or black stools </p><p> Severe headache </p><p> Unusual weakness </p><p> Excessive menstrual bleeding </p><p> Prolonged bleeding from gums or nose </p><p> Dizziness, trouble breathing or chest pain </p><p> Unusual pain, swelling or bruising </p><p> Dark, purplish or mottled fingers or toes </p><p> Vomiting or coughing up blood Symptoms of under-coagulation like the following may signal a life threatening situation: </p><p> Bluish toes/fingers </p><p> Chest/severe back pain </p><p> Blurred vision </p><p> Symptoms of DVT Important: Refer any patient with any presenting symptom(s) to their GP or directly to A&amp;E; especially bleeding or unexplained bruising. </p></li><li><p>7 This document has been developed based on the Scottish Patient Safety Programme </p><p>4. Has the patient been informed about interactions with medicines (prescription, OTC and complementary), supplements, and the effects of food and alcohol? </p><p>Yes No </p><p>Advise patient about the various products that can interact with warfarin. You can refer to the Health Pathways information, the warfarin red book, or the Waitemata DHB warfarin counselling checklist and interactions list. </p><p>https://aucklandregion.healthpathways.org.nz/index.htm?18972.htm </p><p>Advise the patient to check with their doctor or pharmacist before making any lifestyle changes. Eg before starting or stopping any other medicines especially antibiotics, and including OTC, herbal, or complementary medicines, and any big changes in diet. </p><p>Warn about increased bleeding risk with aspirin and NSAIDs. </p><p>5. Has the patient been offered written warfarin information (eg warfarin red book or warfarin patient information)? </p><p>Yes No </p><p>Offered written information means: The patient/carer has been actively asked if they would like to receive written information. </p><p>Examples of warfarin information: </p><p> Warfarin Treatment Booklet "Red Book" available free from Medidata, phone (09) 488-4272 </p><p> SafeRx Warfarin guides available in English, Chinese, Tongan, Samoan, Niuean, Korean www.saferx.co.nz/patient-guides </p><p>6. Have all the measures been met? </p><p>Yes No </p><p>Data collection question </p><p>For all measures to be met, Yes must be ticked for all questions 1 5 </p><p>https://aucklandregion.healthpathways.org.nz/index.htm?18972.htmhttps://aucklandregion.healthpathways.org.nz/index.htm?18972.htmhttp://www.saferx.co.nz/patient-guides</p></li><li><p>8 This document has been developed based on the Scottish Patient Safety Programme </p><p>Patient Outcomes </p><p>For this section, you need to check the patient or carers understanding eg via follow up phone call. Remember to use open questions to hear the answers from the patient. </p><p>Note: If you are unable to locate a patient phone number for one of the 10 sample patients, please note this in the data collection spreadsheet. </p><p>7. Could the patient appropriately tell you when to take warfarin? </p><p>Yes No </p><p>Ask the patient: Tell me, when do you take your warfarin? You may need to prompt them for more information. </p><p>Answer guidance: </p><p> Yes if the patient knows to take it once daily, ideally at the same time each day. </p><p> No if the patient couldnt explain when to take the warfarin </p><p>8. Could the patient appropriately tell you what they would do if they miss a dose of warfarin? </p><p>Yes No </p><p>Ask the patient: Tell me, what would you do if you forgot to take your warfarin? </p><p>Answer guidance (refer to Warfarin Red book or other resource): </p><p> Yes if the patient knows to take it if they remember the same day, but to skip it if theyve missed the dose that day. Carry on from there. </p><p> No if the patient couldnt appropriately explain what they should do if they missed a warfarin dose. </p><p>9. Could the patient identify at least one of the common side effects of warfarin? </p><p>Yes No </p><p>Ask the patient/carer: What are the warfarin side effects to watch out for? </p><p>This question is to assess whether the education provided to the patient was effective. Refer to Question 3 above. </p><p>Answer guidance: </p><p> Yes - if the patient could identify one or more common side effect </p><p> No - if the patient couldnt name any side effects </p><p>10. Could the patient identify at least one appropriate person to ask for help regarding their medicines or side effects? </p><p>Yes No </p><p>Ask the patient/carer: Who can you ask for help if you are worried about your medicines or side effects? Appropriate answers may include examples such as Pharmacist, Pharmacy staff, Doctor, Nurse, hospital staff. </p><p>Answer guidance: </p><p> Yes, completely - if the patient could identify at least one appropriate person to ask for help </p><p> No - if the patient couldnt name any or if information was unclear </p></li><li><p>9 This document has been developed based on the Scottish Patient Safety Programme </p><p>Initial Things to Consider </p><p>- What is the current process for patient education? </p><p>- What warfarin resources do you want to provide to patients? </p><p>- How will you select the 10 patients to collect data on each month? (see Toniq / LOTS </p><p>screenshots attached for more guidance) </p><p>- How will you document warfarin patient education has taken place? </p><p>- How will you document warfarin discussions with prescribers? </p><p>- Who will be responsible for completing the data collection sheet each month? </p><p>- Who will be responsible for submitting the completed data each month? </p><p>- Meet with local GPs to discuss the Safety in Practice programme with focus on warfarin </p><p>- Send letter to GPs regarding Safety in Practice programme with focus on warfarin </p><p>Change Ideas to Consider </p><p>- Discuss results of baseline warfarin data collection at a team meeting </p><p>- Arrange education session for pharmacy team about warfarin and patient education </p><p>- Trial example pharmacy checklist for warfarin education </p><p>- Create warfarin prompt card for education points </p><p>- Optimise use of Self Care Cards </p><p>- Utilise SafeRx patient information leaflet </p><p>- Arrange education session for pharmacy team about atrial fibrillation </p><p>- Provide information to patients/carers about their reason for being on warfarin </p><p>eg information on atrial fibrillation, or DVT/PE </p><p>- Develop a patient evaluation tool, to determine patients understanding immediately after </p><p>providing education, then 1 week later, in order to assess effectiveness of education </p><p>provided </p><p>Please send questions or feedback regarding Safety in Practice to Sarah Young, </p><p>Sarah.Young2@Waitematadhb.govt.nz, mobile 021 537 346, phone 09 486 8920 x 3742. </p><p>mailto:Sarah.Young2@Waitematadhb.govt.nz</p></li><li><p>10 This document has been developed based on the Scottish Patient Safety Programme </p><p>Resources </p><p>o Health Pathways information regarding Warfarin https://aucklandregion.healthpathways.org.nz/index.htm?18972.htm </p><p>o Waitemata DHB Warfarin Counselling Checklist and List of Interactions (included in pack) https://aucklandregion.healthpathways.org.nz/Resources/PWarfarin-Counselli...</p></li></ul>

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