1. Virginia Clough The Chester Anticoagulant Service Countess of Chester Hospital

2. “ Coroner highlights prescribing error after a patient dies from Warfarin overdose ”. BMJ 26th October 2002

3. The Chester Anticoagulant Service 2002 team consultant haematologist - lead clinician clinical pharmacist (& covering colleagues) senior BMS2 0.6 BMS 1 clinical assistant 1 session anticoagulant nurse practitioner 1 part-time nurse (D) 2 part-time DVT nurses (F) 1.0 AC 3 0.5 MLA

5. Problems  Long term sickness of 1 of 2 consultants  Clinical pharmacist → promotion elsewhere  Poor recruitment of pharmacy staff in the NHS  Dosing 100+ patients each afternoon

7. “ ………. Administrative and clerical staff are not amongst the staff who can have authority delegated to them under the terms of a Patient Group Direction”. “……….I therefore think that admin and clerical staff carrying out a dose variation on the basis of any group delegation of authority would be potentially open to prosecution under the Medicines Act ”. Hill Dickinson Solicitors March 2002

8. ∙Establish a “patient group direction” for nurse to issue and administer: Warfarin Vitamin K Low molecular weight heparin ∙Establish a document of “levels of competency” for the DAWN system Solutions

9. Q:How do I know that the anticoagulant team are doing what I think I have trained them to do? Q:How do I look at the quality of performance of individual “dosers” in the team?

10. Chester Anticoagulant Service Group Protocol STAGE 1Run DAWN software with computer dose calculation Batch dose Print labels & stick into books Pass to stage 2 operator for check Find INR’s

11. Chester Anticoagulant Service Group Protocol STAGE 2Accuracy check Check correct label in correct book Sign book Release to post

12. Chester Anticoagulant Service Group Protocol STAGE 3Dose changes : simple includesDose changes due to fluctuation in INR without drug changes excludesNew drugs or new clinical information INR 5 Cardioversion patients

13. Chester Anticoagulant Service Group Protocol STAGE 4Dose changes : complex includesNew drugs or new clinical information INR 5 Immediate action for patients INR >5 “problem” patients

14. Chester Anticoagulant Service Group Protocol STAGE 5Refer to Consultant Haematologist includesReview of target 3.5 INR <1.3 2 successive visits Any patient who is bleeding

15. MLA AC3 BMS 1 BMS 2CNS Pharm Cons increasing competency 5432154321 demographics book checks and release simple dosing complex dosing clinical problems

18. Q:How do I know that the anticoagulant team are doing what I think I have trained them to do? Q:How do I look at the quality of performance of individual “dosers” in the team?

22. any questions?