Chapter 9. Protocols for High-Risk Drugs: Reducing Adverse Drug Events Related to Anticoagulants

Published studies of adverse drug events and multiple case reports have consistently identified certain classes of medications as particularly serious threats to patient safety. These “high risk” medications include concentrated electrolyte solutions such as potassium chloride, intravenous insulin, chemotherapeutic agents, intravenous opiate analgesics, and anticoagulants such as heparin and warfarin. Analyses of some of the adverse events involving these mediations have led to important recommendations regarding their administration. Examples include the use of order templates for chemotherapeutic agents, removal of intravenous electrolyte solutions from general ward stock, and protocols for reviewing the settings of intravenous pumps delivering continuous or frequent doses of opiates. While these recommendations have high face validity, they have generally not been subject to formal evaluation regarding their impact in reducing the targeted adverse events. By contrast, several practices relating to the management of patients receiving anticoagulants have been evaluated quite extensively, and therefore constitute the focus of this chapter. Heparin and warfarin are medications whose use or misuse carry significant potential for injury. Subtherapeutic levels can lead to thromboembolic complications in patients with atrial fibrillation or deep venous thrombosis (DVT), while supratherapeutic levels can lead to bleeding complications. These medications are commonly involved in ADEs for a variety of reasons, including the complexity of dosing and monitoring, patient compliance, numerous drug interactions, and dietary interactions that can affect drug levels. Strategies to improve both the dosing and monitoring of these high-risk drugs have potential to reduce the associated risks of bleeding or thromboembolic events.