Skip to main content
Implementation of an Order Set to Adhere to National Patient Safety Goals for Warfarin Therapy
Hospital Pharmacy
  • Sarah Nisly, Butler University
  • Erin D. Shilz, Indiana University Health
  • Vanessa VanArsdale, University of Cincinnati
  • Jordyn Laughlin, Wabash General Hospital
Document Type
Publication Date
Additional Publication URL
Background: In 2009, The Joint Commission mandated full compliance with National Patient Safety Goal (NPSG) 03.05.01 to reduce the likelihood of patient harm associated with anticoagulant therapy. Methods: We conducted a retrospective chart review of inpatients receiving warfarin at Methodist Hospital pre and post implementation of a warfarin order set between January 2008 and July 2011. The primary endpoint of this study was overall adherence to laboratory monitoring. Secondary endpoints included compliance with individual laboratory parameters, percentage of patient educational sessions completed prior to discharge, and percentage of appropriate follow-up arrangements documented on discharge. Results: A total of 707 patients were assessed. Overall adherence to laboratory monitoring parameters significantly improved from 71.8% to 87.5% (odds ratio [OR], 2.76; 95% CI, 1.87- 4.07; P < .001). Additional improvements were seen in patient education prior to discharge, and appropriate follow-up arrangements were documented at discharge. Conclusions: This analysis demonstrates that implementation of an order set assists in adherence to policies and procedures designed to address the NPSG 03.05.01. Additionally, pharmacy involvement in monitoring, educating, and arranging for follow-up may lead to successful completion of these parameters.
Link leads to full-text provided by: Thomas Land, Inc.
Citation Information
Sarah Nisly, Erin D. Shilz, Vanessa VanArsdale and Jordyn Laughlin. "Implementation of an Order Set to Adhere to National Patient Safety Goals for Warfarin Therapy" Hospital Pharmacy Vol. 48 Iss. 10 (2013) p. 828 - 833
Available at: