Advancing Anticoagulation Stewardship with a New Playbook from NQF
In August 2022, the National Quality Forum (NQF) released Advancing Anticoagulation Stewardship: A Playbook to help healthcare organizations and clinicians improve anticoagulant use and overall patient care. Intended to be applicable to all care settings and all anticoagulation patient populations, the Playbook focuses on the fundamental organizational structures and supports necessary for any successful quality improvement program. Like Safer Together: A National Action Plan to Advance Patient Safety, NQF recognizes that leadership support, infrastructure, and culture of safety are critical components for preventing harm and ensuring safe care. Advancing Anticoagulation Stewardship: A Playbook is a strong example of how the elements of Safer Together can, and should, be applied to any given quality improvement program.
Core Elements of Advancing Anticoagulation Stewardship: A Playbook
Secure administrative leadership commitment
Establish professional accountability and expertise
Engage multidisciplinary support
Perform data collection, tracking, and analysis
Implement systematic care
Facilitate transitions of care
Advance education, comprehension, and competency
Anticoagulant stewardship is a relevant topic here in Oregon. Between 2012 and September 2022, Oregon’s Patient Safety Reporting Program (PSRP) received 62 medication events that involved anticoagulants: 49 from hospitals, 9 from nursing facilities and 4 from pharmacies, half of which (51%) resulted in serious harm or death. Medication events involving anticoagulants were most frequently incorrect dose, omitted, contraindicated, discontinued or incorrect medication events. Oregon facilities recognize that these events are preventable, indicating that 77% of reported events almost certainly or likely could have been prevented.
PSPR reports provide evidence that Oregon facilities are already making headway with one core element from the Playbook: Secure administrative leadership commitment. One recommendation for establishing an antibiotic stewardship program is “Share actual cases of patient harm within the organization to raise awareness, create urgency, and gain buy-in.” 94% (58/62) of medication event reports that involved anticoagulants included participation by senior management in event analysis.
What You Can Do
Whether your organization is looking to establish a new anticoagulation stewardship program or to enhance an existing program, the strategies detailed in the Playbook, which are fundamental to any successful quality improvement program, can be tailored to meet your organization’s needs.