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An audit into the prescribing practices of warfarin in a paediatric setting
  1. NZ Hanif
  1. Birmingham Children's Hospital, Birmingham, England


Objective Evaluate if clinicians at Birmingham Children's Hospital (BCH) are adhering to the warfarin NPSA (National Patient Safety Alert) and to investigate if warfarin has been prescribed and administered correctly according to Trust policies and national guidelines. It is well documented that fatalities associated with warfarin are primarily due to prescribing or dispensing errors.1 The aim of this audit was to identify what prescribing errors are occurring in BCH and to suggest areas for improvement.

Methods A comprehensive systematic literature search was performed searching for the use(s) of warfarin. Once a good background into the clinical uses of warfarin was obtained; patient notes and documentation were looked through for adherence to the warfarin NPSA alert. Adherence was based on specific audit standards derived from the NPSA such as international normalised ratio (INR) levels being documented on drug charts and an indication for warfarin being stated in the notes. Warfarin clinics were visited in which the anticoagulation team provided a good background into the overall prescribing processes of warfarin within BCH.

Results With top line evaluation results identifying two patients to be on concurrent interacting medicines with warfarin (which were not acknowledged), and two patients who had lost drug charts; it remains evident that factors previously identified as leading to warfarin incidents, have continued to happen whilst not precluding its clinical use. Almost 62% of patients had warfarin appropriately prescribed (with regards to stating the drug name, form, route of administration, dose given and monitoring of INR) with 30.7% of patients having corresponding INR monitoring sheets with their drug charts. There was a 28.6% adherence to the expected audit standards, mainly due to missing INR levels being recorded on drug charts. The most profound reason for this was due to the issue of lack of communication between healthcare professionals and a breakdown in processes regarding safe warfarin prescribing, which could be improved by more education and training for all staff.

Conclusion As The authors emerge into an era of increased polypharmacy, the importance for pharmacovigilance has never been more important. More needs to be done in order to increase adherence to local and national guidelines to encourage safe prescribing and more paediatric warfarin patients need to be audited for further conclusive evidence. Areas for improvement that were suggested included proposing a universally accepted protocol for the safer use of warfarin for all clinicians within BCH to implement; and implementing a cautionary warning on the Lorenzo system (electronic software in BCH that records all patient details upon admission) prompting the transfer of warfarin documentation onto current patient files to be used on the ward, so that the most up to date information can be viewed by the multidisciplinary team upon admission. Only then can The authors aim to halt the national instances of warfarin induced fatalities and toxicities.

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