To reduce patient harm from anticoagulation therapy, Fairview pharmacy and administrative leaders have implemented two systemwide policies: Anticoagulation Medication Management and Pharmacy Managed Warfarin Dosing. These policies also address bridging therapy for patients on warfarin therapy who need temporary changes because of surgery or other procedures. The policies comply with goal 3E of The Joint Commission's 2008 National Patient Safety goals to reduce the likelihood of patient harm associated with the use of anticoagulation therapy.

The Fairview clinical system pharmacy group annually reviews system statistics to focus on reducing medication harm and errors (see above). After narcotics and insulin, warfarin is the third most likely drug at Fairview to be associated with patient harm. Other steps to address medication harm and errors include expanding pharmacists' scope of practice to

include ordering narcotic reversal agents and the hypoglycemia protocol.

View the policies (anticoagulation, S:MM-2007 and warfarin dosing, DS:MM-5036) on Fairview's intranet, accessible via portal.fairview.org (password required, call 612-672-6805).

For more information, visit jointcommission.org or ihi.org, or contact Janet Madsen, PharmD, Fairview hospital pharmacy training and knowledge manager, 612-5672-5194, jmadsen1@fairview.org, or Steve Meisel, PharmD, Fairview system director, medication safety, 612-672-7061, smeisel1@fairview.org.

Please share your feedback on this story. Click on the feedback link below.