Clinical pharmacist-led anticoagulation stewardship program: improve physician adherence to evidence-based guidelines and reduce anticoagulant-related medication errors

Background

Due to their high risk of medication errors (MEs) and the potentially devastating thrombotic and bleeding events, anticoagulants are a class of high-risk medications that require regular monitoring by healthcare professionals. The pharmacist is in the ideal position to provide patient care during anticoagulation therapy which is still prone to inappropriate prescribing. The pharmacist is capable of anticoagulation therapy monitoring, provision of drug information, dosing protocol preparation, drug interaction screening, and educating patients. It has been demonstrated that specialized anticoagulation management programs enhance clinical safety and quality of anticoagulant therapy. This study aimed to evaluate the effect of implementing a pharmacist-led anticoagulation stewardship program in reducing anticoagulant-related MEs. We conducted a prospective pre-and post-intervention study in a tertiary hospital on 233 patients with 4132 anticoagulant doses to assess the impact of this program implementation.

Results

This study found that MEs were significantly reduced after implementing the anticoagulation stewardship program. Specifically, the “Medication without indication” and the “Incorrect dose (low dose)” types of MEs were remarkably decreased from 14.4% pre- to 3.3% post-, and from 47.6% pre- to 28.7% post-implementation, respectively. Interestingly, the “Wrong route” disappeared in the post-implementation phase of the study. The proportion of wrong doses/total doses decreased from 0.474 ± 0.044 to 0.432 ± 0.04 (p = 0.003), while category F decreased from 8.3% to 4.7% (p = 0.001). Physician adherence to evidence-based guidelines (EBG) improved as full adherence increased from 38.8 to 60.2% (p = 0.001) and non-adherence decreased from 26.7 to 3.4% (p = 0.001). These statistically significant findings further suggest valuable clinical benefits since implementing this pharmacist-led program could improve patient outcomes by reducing ME and increasing physician adherence to EBG guidelines.

Conclusions

Although the study was limited by the hospital clinical pharmacist team's working hours, as they work 12 h/day rather than 24, and hence, the program was only observed during this time, the study concluded that the anticoagulation stewardship program encouraged the safe use of anticoagulants, lessened MEs and their severity, and improved physician adherence to EBG. Future studies should assess the effect of such programs on other clinical outcomes beyond MEs and determine their impact on healthcare costs.

Clinical Trial registration: Clinicaltrials.gov: NCT03812848. Date: January 1, 2018.