Anticoagulants are one of the classes of medicines most frequently identified as causing preventable harm and admission to hospital. Managing the risks associated with anticoagulants can reduce the chance of patients being harmed in the future. 

In 2006, the NPSA published a risk assessment of anticoagulant therapy and the report identified 15 key areas of risk, many of which relate to poor systems. A fundamental issue is the failure to perform adequate clinical audits of anticoagulant services and failure to act on audit findings. Although the British Society for Haematology( BSH) has made recommendations for audit these are often not followed and, as a result, risk managers are frequently unaware of the risks posed by anticoagulant therapy. Another important factor is that many of the staff who prescribe and monitor anticoagulation therapy have not received adequate training and do not have the required competencies.

Following publication of this risk assessment, a patient safety alert (http://www.npsa.nhs.uk/site/media/documents/2436_Anticoag_alert_FINAL.pdf)

has been developed in collaboration with the British Society for Haematology (BSH) and a broad range of other clinical organisations and individual clinicians, patients and patient groups. This safety alert details eight actions to be completed by anticoagulation providers by March 2008. An audit template is available at www.npsa.nhs.uk/health/alerts

One of the actions is for anticoagulant services to complete audits using BSH/NPSA safety indicators (http://www.bcshguidelines.com/pdf/NPSA_040107.pdf) as part of the annual medicines management audit programme. This guideline provides eight indicators for patients starting on anticoagulants and ten for patients established on warfarin. These indicators can be derived from software systems such as Dawn AC used to support anticoagulation services.

The NPSA has commissioned e-learning modules on initiating and maintaining anticoagulant therapy which can help practitioners assess their current level of competence and provide training covering knowledge and understanding to promote safe practice. The e-learning modules are available at www.npsa.nhs.uk/health/alerts
See also BMJ (British Medical Journal) Learning (http://www.bmjlearning.com) a series of E-modules provided via the internet has been created and from feedback to date are proving to very useful and helpful.

A competence is an expectation of work performance. The process of preparing competences has been established by Skills for Health (www.skillsforhealth.org.uk). Work competences are intended to be multi-disciplinary and outline safe practice for all staff undertaking these responsibilities, including medical staff.

Further recommendations have made on:

• improved information and counseling for patients,
• monitoring and treatment records,
• standardization of range and strength of anticoagulants,
• procedures for patients receiving anticoagulants in care homes,
• managing repeat prescriptions, and the
• management of dental patients.

Finally, an evaluation study of the effectiveness of the safety alert will be conducted by the University of York involving 20 hospitals (Acute trusts) and 20 primary care organizations  (PCTs).