Community Pharmacy Oral Anticoagulant Safety Audit

Community Pharmacy Oral Anticoagulant Safety Audit

The NHS Community Pharmacy Contractual Framework (CPCF) includes a requirement that community pharmacies undertake two clinical audits each year. NHS England determines the topic of one of the audits and community pharmacy contractors are free to determine the topic of the second audit.

This audit has been created by the Specialist Pharmacy Service and is readily available on Pharmoutcomes for all contractors (or local NHS England teams) to use.

Click on a heading below for more information: 

The focus of the audit

Anticoagulants are high risk medicines; they have a heightened risk of causing significant harm when used in error. This class of medicines is frequently identified as a cause of preventable harm and admission to hospital. Ten years ago, the National Patient Safety Agency (now NHS Improvement) issued a patient safety alert with actions to improve anticoagulant safety which included providing specific patient information, regular blood monitoring and checking drug interactions. Since then, new non-vitamin K antagonist oral anticoagulants have come into widespread use. Although the principles of the 2007 alert still apply, some aspects, such as regular Internalised Normalised Ratio (INR) monitoring and dietary consideration, are not relevant for the newer medicines.

Warfarin, the main traditional oral anticoagulant, is widely known to health professionals, but newer agents (apixaban, dabigatran, edoxaban and rivaroxiban) may not be recognised as anticoagulants and this has contributed to various medication errors. Reported errors include inappropriate continuation or discontinuation of anticoagulant therapy, inadvertent co-prescribing with other drugs which increase the risk of bleeding (such as non-steroidal anti-inflammatory drugs and antiplatelets), and concomitant prescribing with other anticoagulants (such as heparin or warfarin).

The purpose of the audit is to make sure people taking anticoagulants know that the medicines affect blood clotting and to check on any relevant safety issues. NHS advice on safe anticoagulant therapy is more than ten years old, and a number of new types of anticoagulants are now in common use in primary care. Whilst the new agents do not require INR monitoring, errors such as the inadvertent co-prescribing with other medicines which can also cause bleeding have been reported to cause potentially avoidable harm.

The key drivers for this audit are:

  • The  recent rapid widespread adoption of non-vitamin K oral anticoagulants, alongside the continued use of vitamin K antagonists, has significant implications for patient safety.
  • Update on current insight from primary care on the use of anticoagulant alert cards and record books to ensure safety.

The aims of the audit are:

  • To determine patients’ awareness of key information about their anticoagulant medicine.
  • To audit current use of anticoagulant alert cards.
  • To audit compliance with national monitoring requirements for vitamin K antagonists.
  • To inform a national update of patient held oral anticoagulant information and alert cards.

How do I undertake the audit?

  1. The full audit details can be downloaded from the SPS website.
    To collect a useful sample for this audit it is suggested that data is collected over approximately two weeks and includes a minimum of 15 patients. You need to speak directly to at least 10 of the patients to complete the audit.
  2. It is recommended that where possible data is entered directly onto PharmOutcomes. However, a paper version of the data collection tool is available on pages 5-8 of the audit manual. Data collected on paper can be entered on PharmOutcomes at a later date if desired.
  3. When you log into PharmOutcomes select Services; you should see Oral anticoagulants under the National Audits heading.
    If you have mislaid your PharmOutcomes login details, visit the Help page.

Audit sample

All patients presenting a prescription for an oral anticoagulant i.e. vitamin K antagonists, factor Xa inhibitors or thrombin inhibitors:

  • acenocoumarol;
  • apixaban;
  • dabigatran;
  • edoxaban;
  • phenindione;
  • rivaroxiban; and
  • warfarin.

Audit standards

All patients prescribed any oral anticoagulant

Standard 1

All patients are aware they are taking an anticoagulant medicine

Audit standard 100%

Standard 2

All patients have an anticoagulant alert card

Audit standard 100%

Standard 3

All patients are aware they need to check with a doctor or pharmacist before taking any over-the-counter medicines

Audit standard 100%

All patients prescribed vitamin K antagonists (warfarin, acenocoumarol or phenindione)

Standard 4

INR monitoring within the last three months is confirmed for all patients before dispensing.

Audit standard 100%

Audit documents

Further resources

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