A prospective audit on adult thromboprophylaxis and therapeutic anticoagulation prescribing and administration practices in Galway University Hospitals
Authors: Hogan-Murphy D , Given J , Dennedy M C , Egan L , Mulry C 
Published: April 2024

Abstract

Introduction
Anticoagulants are high-alert medications that can cause significant patient harm if used inappropriately.[1] These preparations have been identified as a significant medication safety concern in Galway University Hospitals and are one of the most frequently reported medication incidents in Ireland.[2] A key performance indicator agreed by the local Medication Safety Subgroup and Drugs and Therapeutics Committee was to conduct an anticoagulation audit against local guidelines to identify patterns and develop quality improvements.

Methods
A prospective audit was conducted over six weeks from September to November 2022 by five interprofessional data collectors using a data collection tool and accessing drug records and clinical notes. Development of the tool was guided by national[1] and local guidelines as well as design input from local expert specialist doctors and pharmacists. Adult inpatients on all wards receiving thromboprophylaxis (after 24 hours of admission) or therapeutic anticoagulation were included. Paediatrics and psychiatry were excluded. The protocol and tool were approved by the local Clinical Audit Committee, piloted with three inpatients, and communicated to all data collectors prior to commencement. Generated data were anonymous and securely stored. Data analysis was carried out by two independent researchers to confirm reliability of results.

Results
A total of 242 inpatients were audited on 26 wards:
-Patients prescribed thromboprophylaxis (52%; 126/242).
-Patients prescribed therapeutic anticoagulation (26%; 63/242)
-Patients not prescribed anticoagulants (22%; 54/242)
Most patients (92%; 216/234) did not have a thromboprophylaxis risk assessment form completed/signed. Nineteen patients (35%; n=54) not prescribed thromboprophylaxis or therapeutic anticoagulation should have been prescribed anticoagulation.
High compliance with guidelines (&gt;80%) included: i) anticoagulants prescribed in correct section of drug record, ii) appropriate agents prescribed, iii) correct dose and frequency, iv) few dose delays and omissions, and v) indication mostly documented.
Low compliance with guidelines (&lt;35%) included:
-Patient height and weight not documented: unable to calculate creatinine clearance to determine accurate dose.
-Incorrect administration times for once daily therapeutic dosing (should be in morning to facilitate surgery next day) and twice daily dosing (mostly 8am and 10pm = gap of 14 hours and 10 hours).

Conclusion
Results have identified varying levels of compliance with local anticoagulation guidelines. To date, there has been continuous targeted education and training on appropriate anticoagulation use for doctors, nurses, and pharmacy staff inclusive of the development and implementation of a new bespoke eLearning module for high-alert medications (which includes the appropriate use of anticoagulants specific to Galway University Hospitals). High leverage strategies, such as electronic prescribing, is a current consideration to standardise practices. Strengths include study robustness, interprofessional collaboration, and transferability to other hospitals. Perhaps reducing the scope in a re-audit which will be conducted in 2024 to identify any improvements in medication safety and patient care with these agents may allow for further in-depth analysis.

References
1. National Medication Safety Improvement Programme 2018. Preventing Blood Clots in Hospitals: Improvement Collaborative Report National Recommendations and Improvement Toolkit. Health Service Executive. Available from: https://www.hse.ie/eng/about/who/nqpsd/patient-safety-programme/medication-safety/1-hse-preventing-vte-report-2018.pdf
2. State Claims Agency. Medication Incidents Report: A review of medication incidents reported by Irish acute hospitals (2017-2018). Available from: https://stateclaims.ie/uploads/publications/State-Claims-Agency-Medication-IncidentReport_August-2020.pdf