Brace Street Health Centre
Other
Action Taken
Brace Street Health Centre has implemented several changes, including informing Warfarin patients to bring their yellow books to appointments, scanning the books, coding the INR, and implementing a written Warfarin prescribing procedure. They have also undertaken safe prescribing audits and death review audits. (AI summary)
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Dear Mr Zafar, RE: Mrs Annie Lloyd can confirm that these are the improvements that we have implemented to prevent future deaths from occurring:
1. All of our patients (who take Warfarin) have been told that must bring in their yellow Warfarin book every time g0 to have their INR checked at the hospital: The Warfarin book will be scanned and then given to the practice manager who will code the latest INR. She will then enter on to their consultation the date the INR was taken, the result, what dose of medication should be and when their next INR is She will then request the correct strength as per the vellow Warfarin book: The General Practitioner will also check the details before issuing the prescription. 2 We have recently undertaken safe prescribing audits on NSAIDs, Valproates and Lithium_
3. The Practice now has a written Procedure for the process of prescribing Warfarin, checking INR results and altering doses. Please find this document attached, thev they they taking due:
4 We have recently undertaken death review audit so that we can look at the causes of a death and the factors that contributed to it If there are any actions that could prevent future deaths we will put them into practice. 5, Our CCG pharmacist is undertaking Pincer audit regularly to ensure the safety of patients Warfarin: He runs search on the practice computer and prints out a list of patients, if any, who have not had their INR checked recently and gives it to the practice manager: She will then telephone the patient and ask them to bring in their yellow Warfarin book;
6. We have already prevented future problems from happening on two occasions: Date of incident: August 2019 letter from the Cardiologist was received at the practice stating that one of our patients needed to be put on Warfarin: Itelephoned the patient and was told that he had been to the Warfarin clinic and had been started on Warfarin already: was unaware of this as we had not received a letter from the Warfarin clinic informing us of this palso noticed that the patient was prescribed Diclofenac last vear when he was not Warfarin. The patient stated that the Warfarin clinic did not tell him not to take NSAID. warned him that he must not take any Diclofenac, Ibuprofen, Naproxen while he is on Warfarin. also contacted the anticoagulation nurse at the Warfarin clinic who told him that the patient had been seen by them and started Warfarin and letter had been sent to the practice but we did not receive it. also told her that must tell all patients to take their yellow Warfarin book to their General Practitioner. Date of incident: 30th August 2019 The practice manager noticed that one of our patients had been to the Warfarin clinic twice and had his INR checked but had not brought in the yellow Warfarin book to show US. The practice manager also noticed that he had not reduced the dose of Warfarin as per the yellow book taking 30th taking on they
telephoned the Warfarin clinic and told them he had been taking daily continually instead of reducing this to 5.75mgs daily- advised the patient to continue to take 6mgs and for him to have his INR done sooner than planned. The practice manager informed the patient that he must bring in his yellow Warfarin book time he attends the Warfarin clinic so we can have up to date INR readings The patient was also advised that he must follow the Warfarin clinic instructions when told to lower or higher the dose. 7 Further actions we have taken; The receptionist will photocopy and scan the yellow book immediately and then give it to the practice manager who will code the latest INR and check the correct dose: The GP will then check it again. Our pharmacist is quarterly audit to make sure we are not missing any patients. a) The assistant practice manager will check Warfarin requests when the practice manager is on leave: b) We have involved the CCG who will be sending someone from the Medicines Management Team to support the practice with high risk medication reviews: c) Discussion with Medicines Management team took place on Wednesday December 2019. CCG will undertake a shared care meeting to discuss what happened: We now robust system in place to prevent any further recurrence of future deaths from Warfarin.
1. All of our patients (who take Warfarin) have been told that must bring in their yellow Warfarin book every time g0 to have their INR checked at the hospital: The Warfarin book will be scanned and then given to the practice manager who will code the latest INR. She will then enter on to their consultation the date the INR was taken, the result, what dose of medication should be and when their next INR is She will then request the correct strength as per the vellow Warfarin book: The General Practitioner will also check the details before issuing the prescription. 2 We have recently undertaken safe prescribing audits on NSAIDs, Valproates and Lithium_
3. The Practice now has a written Procedure for the process of prescribing Warfarin, checking INR results and altering doses. Please find this document attached, thev they they taking due:
4 We have recently undertaken death review audit so that we can look at the causes of a death and the factors that contributed to it If there are any actions that could prevent future deaths we will put them into practice. 5, Our CCG pharmacist is undertaking Pincer audit regularly to ensure the safety of patients Warfarin: He runs search on the practice computer and prints out a list of patients, if any, who have not had their INR checked recently and gives it to the practice manager: She will then telephone the patient and ask them to bring in their yellow Warfarin book;
6. We have already prevented future problems from happening on two occasions: Date of incident: August 2019 letter from the Cardiologist was received at the practice stating that one of our patients needed to be put on Warfarin: Itelephoned the patient and was told that he had been to the Warfarin clinic and had been started on Warfarin already: was unaware of this as we had not received a letter from the Warfarin clinic informing us of this palso noticed that the patient was prescribed Diclofenac last vear when he was not Warfarin. The patient stated that the Warfarin clinic did not tell him not to take NSAID. warned him that he must not take any Diclofenac, Ibuprofen, Naproxen while he is on Warfarin. also contacted the anticoagulation nurse at the Warfarin clinic who told him that the patient had been seen by them and started Warfarin and letter had been sent to the practice but we did not receive it. also told her that must tell all patients to take their yellow Warfarin book to their General Practitioner. Date of incident: 30th August 2019 The practice manager noticed that one of our patients had been to the Warfarin clinic twice and had his INR checked but had not brought in the yellow Warfarin book to show US. The practice manager also noticed that he had not reduced the dose of Warfarin as per the yellow book taking 30th taking on they
telephoned the Warfarin clinic and told them he had been taking daily continually instead of reducing this to 5.75mgs daily- advised the patient to continue to take 6mgs and for him to have his INR done sooner than planned. The practice manager informed the patient that he must bring in his yellow Warfarin book time he attends the Warfarin clinic so we can have up to date INR readings The patient was also advised that he must follow the Warfarin clinic instructions when told to lower or higher the dose. 7 Further actions we have taken; The receptionist will photocopy and scan the yellow book immediately and then give it to the practice manager who will code the latest INR and check the correct dose: The GP will then check it again. Our pharmacist is quarterly audit to make sure we are not missing any patients. a) The assistant practice manager will check Warfarin requests when the practice manager is on leave: b) We have involved the CCG who will be sending someone from the Medicines Management Team to support the practice with high risk medication reviews: c) Discussion with Medicines Management team took place on Wednesday December 2019. CCG will undertake a shared care meeting to discuss what happened: We now robust system in place to prevent any further recurrence of future deaths from Warfarin.