The American Journal of Medicine Titled the Safety of Warfarin Therapy

The research article published in 2007 by The American Journal of Medicine titled The Safety of Warfarin Therapy in the Nursing Home Setting details the incidence of adverse related events related to warfarin therapy and measures that should have been taken to prevent the events in a 12 month study based in Connecticut. During the study 720 warfarin-related adverse events were identified of which 29% were considered preventable (Gurwitz et al., 2008).

The root cause of these events was ultimately a combination of events and circumstances with an emphasis on human error during the prescribing and monitoring of anticoagulant therapy (Gurwitz et al., 2008). A compilation of errors of this nature is also known as the "Swiss Cheese Model" In this model, the holes in each slice represent a potential pathway for error to occur. The multiple, different layers of Swiss cheese represent a mechanism or opportunity to deter an error, as it is expected that the holes will not align to allow the error to proceed all the way to an adverse event (Department of Community and Family Medicine, 2005) Gurwitz et al., imply that the 29% of warfarin-related errors that were considered preventable occurred as a result of errors that proceeded through multiple layers of the medication management process.

This issue directly relates to nursing care as it is a responsibility of the nurse to adhere to therapeutic protocols and use proper judgment to facilitate medication management. In the nursing home communication between the facility, primary care physician, pharmacy and laboratory is a key factor in the safe and effective management of patients on anticoagulation therapy (Gurwitz et al., 2008). The nurse must ensure that the patient is adhering to specified PT/INR testing and subsequently maintaining appropriate levels. These results must be communicated to the primary care provider and pharmacy to ensure proper dosing is prescribed as well. As with all medication, it is also the nurse's responsibility to appropriately administer the medication using judgment and knowledge to determine how comorbidities, age and other medications will affect the efficacy of the warfarin.

References

Department of Community and Family Medicine, D. U. M. C. (2005). Swiss cheese model. Retrieved from http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html

J. Gurwitz, MD, T. S. Field, DS M. J. Radford, MD, L. R. Harrold, MD, MPH, R. Becker, MD, G Reed, PhD, K. DeBellis, PharmD, J. Moldoff, BA, N. Verzier, MSN, RN. (2008). The safety of warfarin therapy in the nursing home setting. The American Journal of Medicine, 120, 539-554. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17524757