1. Medication Safety & Anticoagulation
Module 3
Medication Safety & Anticoagulation

2. Part I:
Improve the Safety of Using Medications

3. Labeling of Medications
For Perioperative and other Procedural Settings
(Includes Bedside Procedures)
Label ALL syringes, medicine cups and basins
Labeling occurs AFTER the medication is transferred to the syringe of other container
NEVER PRELABEL EMPTY SYRINGES OR BASINS
Label Includes:
Medication Name
Strength
Quantity
Diluent & Volume
Preparation Date

4. Labeling of Medications
For Perioperative and other Procedural Settings
(Includes Bedside Procedures)
Visual and Verbal Verification
Required if the container is handed off to another person to administer or at break/shift relief
Discard any unlabeled containers immediately!

5. Multiple Dose Vials
MDVs should be dedicated to a single patient whenever possible to reduce the risk of contamination.
If multi-dose vials must be used for more than one patient, they should not be kept or accessed in the immediate patient treatment area.
For example Insulin vials in the Emergency Department
If a MDV enters the immediate care area it is to be dedicated to that patient only

6. Proper Handling of Multiple Dose Vials (MDVs)
Disinfect the vial’s rubber septum before piercing by wiping (and using friction) with a sterile 70% isopropyl alcohol, or other approved antiseptic swab. The septum is allowed to dry before inserting a needle or other device into the vial.
No needles are to be left in septum between uses.
MDVs should be discarded within 28 days after opening unless otherwise specified by the manufacturer.
All vials will be discarded whenever sterility is compromised or questionable, including those placed on a used procedure tray or used during an emergency procedure, even if the vial is unopened/unused.

7. Fluids That Are Stored in Warmers
All fluids put into the warmers require specific dating to ensure stability
Label each bag or container with an expiration date that is provided by the manufacturer
BBraun allows 28 days from the day that it was placed in the warmer

8. Look Alike – Sound Alike Medications
These are medications that have the same or similar, name, spelling, or physical appearance
These are reviewed annually and as necessary by the Pharmacy and Therapeutics Committee and approved by the Medical Executive Committee

9. Look Alike – Sound Alike Medications
New Additions for this year

10. Part 2:
Reduce The Likelihood of Patient Harm Associated with the Use of Anticoagulation Therapy

11. Anticoagulants
ONLY oral unit-dose warfarin, prefilled Fragmin syringes, and premixed heparin drips are used at CHSB.

12. Use of Approved Protocols
CHSB Inpatient Anticoagulation Protocol
Available on all units in the Pharmacy Protocol/Formulary Book
Includes warfarin (Coumadin), heparin and LMWH (Fragmin)
Defines roles of RPh, RN, and Dietician

13. Warfarin Pharmacy-dosed protocol Rx will monitor and dose all patients
MUST check/document INR before 1st dose
- Rx will not dispense doses until INR available
- RN must document INR on eMAR prior to each dose
Care Plan must be initiated & updated
- Monitor patient for bleeding
- Check INR
Educate patient re: bleeding, safety precautions
Education must be documented during admission and at discharge

14. Warfarin Food-Drug Interactions Discharge Instructions
Vitamin K in foods
Green, leafy vegetables
spinach, collard greens, brussel sprouts, broccoli
Cranberry juice
Discharge Instructions
Krames On Demand
MUST include:
Compliance and the importance of follow-up monitoring
Potential for adverse drug reactions and interactions

15. Heparin NPSG includes therapeutic heparin
Heparin flushes, prophylactic doses excluded
MUST use premade heparin drips
Do NOT mix a heparin drip
MUST use the drug library on the infusion pumps when administering

16. Heparin Protocol Bolus Doses – use 1000 units/ml ONLY
NEVER bolus from the infusion bag!
Weight-based dosing
Monitoring
aPTT
Baseline
every 6 hours after ANY dosage change
6 hours after first therapeutic aPTT
every 24 hours after 2 consecutive aPTT
CBC with platelets
every 3 days

17. Heparin Protocol Adjusting the rate:
aPTT <60: bolus dose and ↑ rate
aPTT 60-90: NO ADJUSTMENT
aPTT >90: hold drip and/or ↓ rate
Recheck the aPTT in 6 hours
Document all bolus doses and rate changes on eMAR
Each bolus dose is documented on eMAR
Any rate changes and each bag change are document on eMAR

18. Low Molecular Weight Heparin (Fragmin)
NPSG includes therapeutic doses
Low-dose for DVT prophylaxis excluded
Baseline labs required
CBC with platelets

19. Pradaxa (Dabigatran) Baseline laboratory tests: PT/INR SCr
Ongoing laboratory tests:
SCr every 7 days
Pharmacy will adjust dose as needed for renal function

20. Xarelto (Rivaroxaban)
Baseline laboratory tests:
CBC
SCr
Ongoing laboratory tests:
SCr every 7 days
Should be avoided in patients on dialysis
Medication should not be crushed
Give with food for better absorption

21. Eliquis (Apixaban)
Baseline laboratory tests:
CBC
LFTs

22. Patient Education Only Krames On-Demand will be used
Coumadin (warfarin)
Heparin
Fragmin
Pradaxa
Xarelto & Eliquis

23. Thank You