Category: Adverse Drug Events

VTE & VTE/COVID-19 Resources

North American Thrombosis Forum (NATF)

The North American Thrombosis Forum is dedicated to saving lives through education and prevention. A major part of this is helping healthcare professionals stay up to date on the latest research in the rapidly changing field of thrombosis. Through educational events and informative articles geared specifically towards clinicians, NATF provides clinicians with the information they need to best treat their patients. Topics covered include thrombosis, stroke prevention, atrial fibrillation, diabetes, cardiovascular-related illnesses, and more. Check back regularly for important updates on everything from the development of new medications to the release of novel research.

Managing the Risks of Direct Oral Anticoagulants

The Joint Commission: Sentinel Event Alert

While DOACs offer ease of use to patients, stopping bleeding events in patients on DOACs is more complicated, requiring different strategies than those for patients on warfarin (Coumadin®) and heparin. Unlike the more widely available reversal agents for warfarin and heparin, reversal agents for DOACs are lesser known and may not be available in every care setting. Also, some DOACs have no FDA-approved reversal agent at this time. Therefore, bleeding complications can be severe if these patients are not assessed according to guidelines on the management of DOACs. Intracranial hemorrhage is the most serious emergent bleeding risk.

In response to an increase in adverse events related to these widely prescribed medications, this alert provides guidance on the safe use and management of DOACs to all medical practitioners and health care organization leaders, particularly chief medical officers, pharmacists, emergency department clinicians, and quality and safety officers.

Anticoagulation FORUM: Numerous Resources and Expert Guidance

Anticoagulation FORUM

  • Education & Guidance
  • Webinars and Events
  • Centers of Excellence
  • Anticoagulation Stewardship

Established more than 25 years ago, the Anticoagulation Forum is the largest organization of its kind helping practitioners improve patient care by providing current and relevant information on best practices. The flagship program, the Anticoagulation Centers of Excellence, embodies our commitment to the clinical application of evidence-based practices and improved patient outcomes. Expert Guidance is provided by the Board of Directors, who are regularly relied upon for their expert opinion. Their contributions to research and guideline development have influenced all aspects of anticoagulation therapy.

Preventing Hospital-Associated Venous Thromboembolism: A Guide for Effective Quality Improvement

Agency for Healthcare Research and Quality (AHRQ)

Pulmonary embolism resulting from deep vein thrombosis—collectively referred to as venous thromboembolism—is the most common preventable cause of hospital death. Pharmacologic methods to prevent venous thromboembolism are safe, effective, cost-effective, and advocated by authoritative guidelines, yet large prospective studies continue to demonstrate that these preventive methods are significantly underused. Based on quality improvement initiatives undertaken at the University of California, San Diego Medical Center and Emory University Hospitals, this guide assists quality improvement practitioners in leading an effort to improve prevention of one of the most important problems facing hospitalized patients, hospital-acquired venous thromboembolism.

Opioid Stewardship: IPRO HQIC, Learning and Action Network (LAN)

IPRO HQIC

IPRO Hospital Quality Improvement (HQIC), Learning and Action Network (LAN) webinar on the All-Cause Harm focus are of Opioid Stewardship: April 26th 2021.

IPRO HQIC presented aggregate baseline data on the Opioid Stewardship Hospital Baseline Assessment and heard from a rural hospital on promoting the safe use of opioids (prescribing policy, scripted communication tools, alternatives to opioids, tracking prescribing practices, referral network for pain management, and MAT therapy).

In addition, IPRO HQIC highlight many salient opioid stewardship resources on processes that support the inclusion of patient and family engagement and health equity (stigma) in opioid stewardship efforts. These resources further support IPRO HQIC hospital efforts in All-Cause Harm reduction.

Recording, Slides and All-Cause Harm Resource available.

Direct Oral Anticoagulant: DOAC Playbook

Anticoagulation Forum

Although DOACs require less intensive dose management than warfarin, they are not devoid of potential complications. Anticoagulants have consistently ranked as the class of medications most frequently leading to emergency room visits and hospital admissions for adverse drug events. This toolkit explains how to use DOACs safely and effectively requires that all aspects of anticoagulation therapy are addressed, including appropriate patient selection, dosing, monitoring, transitions between therapies and between care settings, periprocedural guidance, management of risks (including DOAC associated
bleeding), drug-drug interaction management, ongoing assessment of patient and family educational needs, and incorporation of evidence-based practices into workflow.

All-Cause Harm Resource

IPRO HQIC

This resource explains what All-Cause Harm is, why it is important, and then dives into each of the processes it takes to prevent All-Cause Harm. Eight priority focus areas for the Hospital Quality Improvement Contract (HQIC) are illuminated and strategies to monitor compliance are provided.

All-Cause Harm Resource, Recording and Slides from the IPRO HQIC All-Cause Harm “launch” on March 29th, 2021.

Your Guide to Controlling & Managing Pain After Surgery

MHA Keystone Center

This resource provides education to patients related to:

  • Understanding surgical pain
  • Understanding pain after surgery
  • Questions to ask before surgery, after surgery and before discharge
  • Tools to help manage pain
  • Keeping track of pain medications and frequency
  • Common pain medication side effects

The Michigan Opioid Safety Score (MOSS): A Patient Safety and Nurse Empowerment Tool

Journal of PeriAnesthesia Nursing

The Michigan Opioid Safety Score (MOSS) was developed to incorporate patient risk, respiratory rate, and sedation into one bedside score that could be used to improve patient safety during inpatient opioid therapy. Scoring is based on a summation of risk data with objective bedside measures of over-sedation trumping a patient’s subjective reports of pain.

Opioid Overdose Prevention TOOLKIT & Opioid Use Disorder Facts

Substance Abuse and Mental Health Services Administration (SAMHSA)

This toolkit offers strategies to health care providers, communities, and local governments for developing practices and policies to help prevent opioid-related overdoses and deaths. Access reports for community members, prescribers, patients and families, and those recovering from opioid overdose.

  • Scope of the Problem
  • Strategies to Prevent Overdose Deaths
  • Resources for Communities