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Hosp Pharm. 2013 Nov;48(10):828-32. doi: 10.1310/hpj4810-828.

Implementation of an order set to adhere to national patient safety goals for warfarin therapy.

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Clinical Pharmacist, Internal Medicine, Indiana University Health, Methodist Hospital, and Assistant Professor, Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis, Indiana;
Clinical Pharmacist, Internal Medicine, Indiana University Health, Methodist Hospital;
Pharmacy Practice Resident, UC Health, University Hospital, Cincinnati, Ohio;
Pharmacist, Wabash General Hospital. Mt. Carmel, Illinois. Corresponding author: Sarah Nisly, PharmD, BCPS, Butler University College of Pharmacy and Health Sciences, 4600 Sunset Avenue, Indianapolis, IN 46208; phone: 317-962-3410; fax: 317-963-5397; e-mail:



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.


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.


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.


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.


National Patient Safety Goal; follow-up; laboratory monitoring; warfarin

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