The medication I will be discussing is Warfarin, also known as Coumadin. Warfarin is classified as an anticoagulant (blood thinner) and is prescribed to prevent blood clots from forming. This drug aids in thinning the blood throughout the body to reduce the chances of potentially harmful clots from occurring such as in the lungs (pulmonary embolism, PE) or in the legs (deep vein thrombosis, DVT). Harmful clots can also result in a heart attack or a stroke. Vitamin K helps the liver produce proteins in the blood that aid in the formation of clots and is also the reversal agent of Warfarin. Warfarin works against vitamin K by interfering with the effects of it therefore prolonging the time for a blood clot to form (Warfarin Interactions with Food, 2020).
Increased bleeding is the most common adverse event for Warfarin and can cause potential problems. For example, a patient with an injury may have a difficult time in stopping the bleeding. Education is essential to ensure the safety of the patient. It is important to contact the healthcare provider prior to any medical or dental procedures to ensure the drug regimen is stopped at least five days prior to the operation. Some ways to prevent injuries from occurring consists of avoiding sports involved with contact, putting fall precautions in place with a history of falls, utilizing a toothbrush with a soft bristle, an electric razor to shave, and waxed dental floss. A medication error, incorrect usage, changes in diet, and illnesses can also result in adverse events with this prescribed medication. The dosing of Warfarin should have clear labeling with precise instructions explaining exactly how the medication should be taken. The patient’s comprehension of the medication is important to ensure its effectiveness. The storage of the drug as well as checking the expiration date prior to administration should be discussed (Warfarin Side Effects: Watch for Interactions, 2020). Vitamin K in the diet may change to ensure Warfarin is effective. A consistent and an adequate intake of vitamin K is significant while on this drug regimen treatment. Fluctuations in consumption of vitamin K in the diet can cause the prothrombin time (PT) and international normalized ratio (INR) to change. Green leafy vegetables such as lettuce, broccoli, and spinach are a great source of vitamin K to include in the diet (Warfarin Interactions with Food, 2020). Warfarin can also have interactions with certain drugs or supplements. These interactions can result in an adverse event to occur and affect the level of Warfarin. The physician should reconcile the list of medications and supplements the patient is taking to ensure there are no drug-drug interactions (Warfarin Side Effects: Watch for Interactions, 2020).
Adverse events of Warfarin occur approximately 3% to 8% depending on the underlying circumstances. The estimate of significant bleeding while on treatment of Warfarin is 2.3% per year. The prothrombin time (PT) is used to observe the levels of Warfarin. The international normalized ratio (INR) was developed to establish a persistent and regulated replica for PT. Observation of INR was performed often and started while on Warfarin treatment until an optimal therapeutic range was achieved. Monitoring of Warfarin is essential to manage anticoagulation in the therapeutic window. Elevation of international normalized ratio (INR) is a solid predictor of adverse events related to drug association. An increased INR was associated with harm (96% of INRs >5.0). Inadequacy of daily INR measurements was identified with a high risk of over anticoagulation. Metersky et al. (2016) stated “a 1‐day increase in the INR of 0.9 predicted subsequent over anticoagulation. These results provide actionable opportunities to improve safety in some hospitalized patients receiving warfarin.”
A root cause analysis (RCA) is a method used in healthcare to identify and analyze underlying problems leading up to an error causing harm to a patient. Data is collected and reorganized through review by a multidisciplinary team put together consisting of different people from various areas. Reviewing events through the order of the process of what caused harm to the patient identifies and addresses the root cause. It is essential to determine what and why the event happened and how to prevent it from occurring again. This will improve that area where the error occurred for improvement performances and patient safety. A technique known as the Fishbone Diagram can be used to sort through the possible causes into various categories that branch off the original problem. The diagram gives a visual image of a fishbone with the spine located in the middle illustrating the specific problem and the rib bones of the skeleton describing the potential causes located in the different categories. The mind map allows the team to see the overall picture of the problem by linking the events by exploring the potential or actual causes that resulted in single or multiple failures. The 5 Whys can be used in combination with the Fishbone Diagram. After brainstorming and all data is established on the Fishbone Diagram the 5 Whys technique is done to get to the root cause of the issue. The Fishbone Diagram portrays data in a neat, structured, organized, and comprehensive way by displaying the relationships clearly and logically, showing all the causes simultaneously, facilitating brainstorming, stimulating the problem, and help maintain team focus. The 5 Whys technique prompts the team to go further as to what happened to get to the root cause of the problem. This is an effective tool that is simple way to analyze the cause and effect relationships of a specific situation (Root Cause Analysis, 2019).
Failure mode and effects analysis (FMEA) evaluates processes to identify possible failures and correct the processes rather than responding after a failure has occurred. This recognizes where systems may fail leading to harmful outcomes. Leadership establishes a positive environment and a proactive program for identifying risks to patient safety. Leaders focus on identifying primary methods for every organization’s clinical structure, processes, and outcomes for patient quality and safety. A leader empowers the staff and contributes the appropriate training and teaching equipping them with the proper tools and necessary skills to perform the job correctly. Reduction in sentinel events and reduction of medical/healthcare errors are also important healthcare disciplines. For every potential mistake, it is important to work through the order of the process to resolve the error. Examine methods to avoid the mistake from occurring through analyzing the point of origin (FMEA, 2020).
