Red blood cells

Cardiovascular

Quality improvement study improves the safety of prescribed direct oral anticoagulants

The work described here was presented at the Pharmacy Together 2019 conference.

The pharmacy anticoagulant team at Royal Glamorgan Hospital manage all direct oral anticoagulants (DOAC) prescriptions. The majority used for venous thromboembolism (VTE) are prescribed via the ambulatory emergency care unit (AECU), while DOACs for atrial fibrillation are prescribed via various routes. 

Oral anticoagulants are high-risk. DOACs, while perceived as easier than warfarin, are not without problems. Despite the robust anticoagulant service at Royal Glamorgan Hospital, the pharmacy team intervene on almost 90 percent of all DOAC scripts to ensure patient safety. Reviews also identified times where a DOAC already prescribed for VTE was not the most appropriate choice, warranting a switch in treatment. Reviewing DOAC scripts for problems also led to repetition of work within the pharmacy team. Scoping was required to identify why so many interventions were made on DOAC scripts, to review workflow and identify areas of inefficiency.

Several tools were used to define the problem and generate solutions, including: 

  • process mapping
  • a fishbone diagram
  • Pareto analysis
  • stakeholder analysis 
  • construction of a driver diagram.  

Problem categories varied, but included incomplete information on prescriptions, drug interactions and incorrect renal function calculations.  

The outcome measures generated were the number of DOAC scripts that required a pharmacist intervention, and the number of patients that needed to change anticoagulant therapy after already starting treatment.

Interventions on DOAC prescriptions were reduced to 20 percent or less, and no patients required a change of medication mid-treatment

Pareto analysis confirmed that the ambulatory emergency care unit was the ideal target for the interventions. The pharmacy anticoagulant team, ambulatory emergency care unit consultants and staff were engaged throughout due to clear communication and involvement in the scoping sessions. 

The interventions generated were:

  1. To create and display an educational poster in the ambulatory emergency care unit
  2. To create a telephone checklist to screen new referrals to the anticoagulant team to identify potential problems at the start
  3. To run an educational session for ambulatory emergency care unit consultants and staff on the routine problems with DOAC scripts and how to address them.

These were run over a four-week period in December and January 2018.

Our outcome measure targets were to reduce the number of pharmacist interventions needed on DOAC scripts to 20 percent by the end of February 2018, and to reduce the number of patients that need to change anticoagulant therapy after already starting treatment to zero by the end of February 2018.

Our outcome measures were met by implementing three simple, cost-free cycles. Interventions on DOAC prescriptions were reduced to 20 percent or less, and no patients required a change of medication mid-treatment. Preventing the need to change therapy mid-treatment preserved the trust between patient and healthcare provider. 

These measures have improved the efficiency of our pharmacy work systems, promoted patient safety and built on our excellent working relationship with ambulatory emergency care unit staff. Consideration of human factors and clear communication throughout cemented this success. 


This work was presented as a poster at the Pharmacy Together 2019 conference, organised by UKCPA and Pharmacy Management.

Additional authors:

Clara Danielsen and Sue Wooller, Pharmacy Department, Royal Glamorgan Hospital, Cwm Taf Morgannwg University Health Board, Llantrisant.

The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.

Competing interest statement: 

The author declares: no support from any organisation for the submitted work; she has received honoraria from Bayer and Pfizer/BMS in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

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