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Safe Management of Warfarin and Anticoagulant Therapy Policy

1. Purpose

The purpose of this policy is to ensure that {{org_field_name}} maintains a safe, effective, and compliant approach to managing warfarin and other anticoagulant therapies for service users receiving domiciliary care. Anticoagulant medications, including warfarin, rivaroxaban, apixaban, dabigatran, and edoxaban, are high-risk medicines that require careful monitoring, administration, and documentation to prevent serious complications such as excessive bleeding or clot formation.

This policy supports compliance with the Regulation and Inspection of Social Care (Wales) Act 2016, the Regulated Services (Service Providers and Responsible Individuals) (Wales) Regulations 2017, as amended, including Regulations 12, 15, 21, 34, 36 and 58, and the associated Welsh Government statutory guidance. For adults receiving domiciliary support, the policy also has regard to NICE Guideline NG67, Managing medicines for adults receiving social care in the community, and NICE Quality Standard QS171, Medicines management for people receiving social care in the community. The service must provide anticoagulant support in accordance with the individual’s current prescription, personal plan, medicines-support assessment and instructions issued by the prescribing or anticoagulation service.

Where the person receiving care is under 18 years of age, anticoagulant support must be provided strictly in accordance with the child’s individual health plan, prescription, personal plan and written instructions from the responsible paediatric, haematology or anticoagulation team. Adult anticoagulation guidance must not be applied to a child unless the responsible prescribing clinician has confirmed that it is appropriate.

2. Scope

This policy applies to:

• All staff members, including care workers, senior care staff, and managers, who may assist in monitoring, recording, or administering anticoagulant therapy.
• Service users who are prescribed warfarin or other anticoagulants and receive domiciliary support.
• The policy applies only where the provider’s assessment and the individual’s personal plan confirm that staff are required to prompt, assist with or administer the anticoagulant. Staff must not provide medicines support that has not been assessed, agreed and recorded.
• Healthcare professionals and third parties involved in anticoagulation monitoring, including GPs, pharmacists, and specialist anticoagulation clinics.

3. Understanding Anticoagulant Therapy Risks

Anticoagulant medications prevent blood clot formation but pose risks if not managed properly. Common risks include:

• Excessive bleeding (e.g., nosebleeds, bruising, internal bleeding).
• Clotting complications if the medication is not taken correctly.
• Drug interactions with other prescribed or over-the-counter medications.
• Dietary interactions (e.g., vitamin K-rich foods affecting warfarin levels).

To ensure safe and effective care, {{org_field_name}} follows a structured approach to monitoring, administration, and documentation.

3.1 Distinction Between Warfarin and Direct-Acting Oral Anticoagulants

Warfarin and direct-acting oral anticoagulants must not be managed as though they have identical monitoring and dosing requirements.

• Warfarin doses may change following blood-test monitoring and must be administered only from a current, authorised written dosage instruction.
• Apixaban, dabigatran, edoxaban and rivaroxaban are direct-acting oral anticoagulants. They are normally prescribed as a fixed dose and are not routinely monitored using an INR test.
• Staff must not request, interpret or use an INR result to determine the dose of a direct-acting oral anticoagulant.
• Different anticoagulants have different instructions for missed or delayed doses. Staff must follow the individual’s prescription and written instructions from the prescriber, pharmacist or anticoagulation service.
• Staff must never substitute one anticoagulant for another or assume that instructions relating to warfarin apply to another anticoagulant.

4. Roles and Responsibilities

4.1 Responsibilities of Care Staff

Care staff must not make any decisions regarding warfarin dosages but are responsible for:

• Administering or supporting the person to take the anticoagulant only where this is authorised in the individual’s personal plan and only in accordance with the current dispensing label, medicines administration record and, for warfarin, the current written dosage instruction issued or confirmed by the prescriber or anticoagulation service.
• Documenting medication administration accurately.
• Observing and reporting signs of bleeding or clotting complications.
• Ensuring compliance with GP or specialist instructions.

• Checking that the prescription, dispensing label, medicines administration record and any anticoagulation record are consistent before administration.
• Withholding administration and obtaining advice from the manager, supplying pharmacy, prescriber or anticoagulation service where instructions are absent, illegible, expired, contradictory or unclear.
• Never calculating, changing, omitting or restarting an anticoagulant dose unless this is expressly directed by an authorised prescriber or anticoagulation service.
• Following the individual’s agreed emergency and escalation instructions and recording all action taken.
• Monitoring for potential side effects and seeking urgent medical attention if required.

4.2 Responsibilities of the Registered Manager

The Registered Manager must ensure that:

• An individual medicines-support assessment and anticoagulant risk assessment are completed before staff provide anticoagulant support.
• The individual’s personal plan clearly states whether the person self-administers, requires prompting, requires assistance or requires administration by trained staff.
• The personal plan identifies the anticoagulant, indication where known, prescribed dose, usual administration time, responsible prescriber, supplying pharmacy, relevant anticoagulation service, monitoring arrangements and escalation instructions.
• For warfarin, a reliable system is in place for obtaining, verifying, communicating and recording the current authorised dose and the date of the next required blood test.
• Staff do not administer warfarin where a current authorised dosage instruction is unavailable or where records conflict.
• Staff receive medicines training relevant to their role and anticoagulant-specific training before undertaking the task.
• Staff competence is assessed and documented before they administer or support anticoagulant medicines and is reassessed where concerns, errors, changes in practice or changes in the person’s needs arise.
• Any healthcare task delegated to care staff is supported by written delegation, training, competence assessment, defined accountability and arrangements for review.
• Medication errors, omissions, refusals, adverse effects and near misses are reported, responded to, investigated and reviewed in accordance with the organisation’s medication and incident-management procedures.
• Medicines-management audits include anticoagulant records, current dosage instructions, medicines administration records, missed monitoring, incidents, staff competence and action taken following identified shortfalls.
• Appropriate information is shared promptly with the individual, their representative where lawful and appropriate, the prescriber, pharmacy, anticoagulation service, commissioners, safeguarding authorities and CIW where the circumstances meet the relevant reporting or notification threshold.

4.3 Responsibilities of Healthcare Professionals

• The authorised prescriber and relevant anticoagulation or specialist service are responsible for clinical decisions concerning the choice of anticoagulant, dose, monitoring requirements and treatment changes. Pharmacists are responsible for dispensing against a valid prescription and may provide medicines information and advice within their professional role. INR monitoring applies to warfarin and certain other vitamin K antagonists; it does not routinely apply to direct-acting oral anticoagulants.
• Care staff liaise with healthcare professionals if there are concerns about dosage changes, missed doses, or signs of adverse effects.

5. Assessment, Consent, Capacity and Level of Medicines Support

5.1 Medicines-Support Assessment

Before staff provide any support with an anticoagulant, the service must assess and record:

• The person’s ability and wish to manage their own medicine.
• The exact support required, including whether staff will prompt, assist or administer.
• The person’s physical, cognitive, communication and sensory needs.
• Known risks, including previous bleeding, falls, missed doses, duplicate doses, medicine interactions, alcohol use and difficulties obtaining prescriptions or attending monitoring appointments.
• The responsibilities of the person, their representative, care staff, prescriber, supplying pharmacy and anticoagulation or specialist service.
• How current dosage and monitoring information will be obtained and communicated.
• What staff must do if the medicine, dose, instructions or monitoring information is unavailable or unclear.

5.2 Consent and Mental Capacity

Staff must obtain the person’s valid consent before providing medicines support. Consent and the agreed level of support must be recorded in the personal plan.

Where there is reason to doubt the person’s capacity to make a particular decision about their anticoagulant treatment or medicines support, staff must follow the Mental Capacity Act 2005. Capacity must be considered in relation to the specific decision and at the time the decision is required. Any best-interests decision must be made and recorded in accordance with the Act and must involve relevant persons and professionals.

Staff must not administer an anticoagulant covertly unless a lawful, person-specific best-interests process has been completed, the prescriber and pharmacist have provided appropriate written instructions and the decision is documented and regularly reviewed.

5.3 Self-Administration

The person must be supported to manage their own anticoagulant wherever this is safe and consistent with their wishes and assessed needs. Any decision for staff to take over part or all of the person’s medicines management must be proportionate, agreed and recorded. The arrangements must be reviewed following any change in the person’s health, cognition, treatment, ability or wishes.

6. Safe Administration of Warfarin and Anticoagulant Therapy

6.1 Warfarin Dosage Instructions and INR Monitoring

Warfarin must be administered only where the service holds a current, legible and authorised written dosage instruction. The instruction may be contained in an anticoagulation record, written dosing schedule, prescription or other authorised record accepted under the organisation’s medicines procedure.

Staff must:

• Confirm the prescribed warfarin dose against the current authorised dosage instruction and medicines administration record before administration.
• Check that the person’s identity, medicine, strength, dose, date and administration time are correct.
• Confirm that the date of the next required INR test is recorded.
• Record the dose administered immediately after administration.
• Record and escalate any missed, refused, delayed or vomited dose.
• Record and escalate any missed or overdue INR appointment.
• Obtain advice before administration where the dose is unclear, the instruction has expired, the next-test date has passed, the person reports that treatment has changed or the available records do not agree.

Care staff must not interpret an INR result, calculate a dose or amend the dosage schedule. A result must be reviewed and converted into a clear dosage instruction by the authorised prescriber or anticoagulation service.

Direct-acting oral anticoagulants must be administered according to their current prescription and do not require routine INR monitoring.

6.2 Medication Administration Guidelines

• Warfarin must be administered according to the current dispensing label, medicines administration record and authorised written dosage instruction. Where these records conflict, staff must not administer the medicine until the discrepancy has been resolved by an authorised healthcare professional.

• Staff must never alter the dose or make independent decisions about administration.
• Where the personal plan requires staff to administer the medicine, staff must observe administration sufficiently to establish that the medicine has been taken, while respecting the person’s dignity and consent. Administration must be recorded immediately on the medicines administration record. Staff must not record administration before the medicine has been taken.
• If a dose is missed, delayed, refused, spat out or vomited, staff must not give a replacement or double dose unless expressly instructed by an authorised healthcare professional. Staff must follow the person-specific instructions in the personal plan or dispensing information and obtain timely advice from the prescriber, anticoagulation service, supplying pharmacy, NHS 111 Wales or emergency services, according to the urgency and circumstances. The event, advice received, action taken and persons informed must be recorded.

• Staff must check and document allergies and must ask the person whether they have already taken the dose where there is any uncertainty. If administration cannot be confirmed, staff must not give another dose until professional advice has been obtained.
• Anticoagulant medicines must not be crushed, opened, mixed with food or altered from their original form unless an authorised prescriber or pharmacist has confirmed in writing that this is safe and appropriate for that individual medicine and person.
• Staff must use only the medicine supplied for the named individual and must not use another person’s supply.

6.3 Storage and Handling of Anticoagulants

In a domiciliary support service, medicines normally remain the property and responsibility of the individual. Storage arrangements must promote independence while managing any assessed risk.

• Anticoagulants must be stored in accordance with the dispensing label, manufacturer’s instructions and the person’s medicines-support assessment.
• Medicines must be kept in their original labelled packaging unless an alternative dispensing system has been supplied or authorised by the pharmacy.
• Secure storage must be used only where this is required by an individual risk assessment or agreed as part of the person’s medicines-support arrangements.
• Medicines must be protected from excessive heat, moisture, direct sunlight and access by children or other persons where this presents a risk.
• Staff must not remove or dispose of discontinued, expired or unwanted medicines without the individual’s consent or other lawful authority. Disposal must be arranged through an appropriate community pharmacy or other authorised route, and a record must be made where staff facilitate the return.
• Staff must perform hand hygiene before and after providing medicines support. Gloves are not routinely required for the handling of intact tablets or medicine packaging. Gloves or other personal protective equipment must be used where indicated by an infection-prevention risk assessment, the nature of the preparation or the manufacturer’s instructions.

7. Recognising and Responding to Side Effects and Emergencies

7.1 Signs of Excessive Anticoagulation (Bleeding Risks)

Care staff must immediately report and escalate if a service user experiences:

• Unusual bruising or prolonged bleeding from cuts.
• Nosebleeds lasting more than 10 minutes.
• Blood in urine or stools (red or black).
• Unexplained severe headaches or dizziness (possible internal bleeding).
• Coughing up blood or vomiting blood.

Staff must treat severe, uncontrolled or unexplained bleeding, vomiting or coughing blood, suspected internal bleeding, sudden severe headache, collapse, marked confusion, breathing difficulty, or any significant head injury as a medical emergency and call 999.

Any fall, blow to the head or suspected head injury involving a person taking an anticoagulant must be escalated promptly for clinical assessment, even where there is no obvious external bleeding. Staff must follow NHS 111 Wales, emergency-service or prescriber advice and must not rely solely on visible symptoms.

Less severe bleeding, repeated minor bleeding, unexplained bruising or a significant change in the person’s condition must be reported promptly to the manager and referred for clinical advice in accordance with the personal plan.

6.2 Signs of Inadequate Anticoagulation (Clotting Risks)

Emergency medical attention is required if a service user experiences:

• Sudden chest pain or difficulty breathing (possible pulmonary embolism).
• Leg swelling or pain (possible deep vein thrombosis).
• Sudden weakness, numbness, or speech difficulty (possible stroke).

If any of these symptoms occur, staff must call 999 immediately, provide first aid within their competence, remain with the person where it is safe to do so, make the person’s medicines information available to the emergency service and notify the Registered Manager. The GP or specialist team must be informed after urgent emergency action has been initiated, where appropriate.

8. Dietary and Drug Interactions

8.1 Food, Alcohol and Dietary Considerations

Dietary advice must be individualised and must not be used by care staff to change, restrict or stop a person’s normal diet without advice from an appropriate healthcare professional.

• People taking warfarin should generally maintain a consistent, balanced diet rather than avoid all foods containing vitamin K.
• Significant or sudden dietary changes, reduced food intake, vomiting, diarrhoea, acute illness or changes in alcohol consumption must be reported because they may affect anticoagulant safety or warfarin control.
• Staff must follow any person-specific dietary or alcohol advice issued by the prescriber, anticoagulation service, pharmacist or dietitian.
• Food interaction advice applicable to warfarin must not automatically be applied to a direct-acting oral anticoagulant.
• Care staff must not recommend dietary supplements, herbal remedies or major dietary restrictions.

8.2 Prescribed, Non-Prescribed and Complementary Medicines

Anticoagulants can interact with prescribed medicines, over-the-counter medicines, herbal products and supplements. Staff must:

• Administer only medicines that have been authorised, supplied for the individual and recorded on the current medicines administration record.
• Ask the person to inform the service, prescriber, anticoagulation service and supplying pharmacy before starting, stopping or changing any prescribed, over-the-counter, herbal or complementary product.
• Report any newly supplied medicine, including antibiotics, anti-inflammatory medicines, antiplatelet medicines and herbal products, to the manager so that the current care records and risk assessment can be checked and updated.
• Seek advice from a pharmacist, prescriber or anticoagulation service where there is uncertainty about an interaction.
• Never advise the person to stop an anticoagulant or another prescribed medicine.

Staff must not administer aspirin, ibuprofen or another non-steroidal anti-inflammatory medicine unless it has been prescribed or otherwise clinically authorised for that person and is included in the medicines administration arrangements. Paracetamol must also be used only in accordance with its authorised directions because regular or excessive use may require clinical review in a person taking warfarin.

9. Training, Competence and Delegated Tasks

Staff must not administer or provide assessed assistance with an anticoagulant until they have:

• Completed the organisation’s medicines training appropriate to their role.
• Received anticoagulant-specific instruction covering warfarin, direct-acting oral anticoagulants, bleeding and clotting risks, missed doses, medicine interactions, record keeping and emergency escalation.
• Been assessed as competent in the specific medicines-support tasks they will perform.
• Demonstrated that they can identify the current authorised dosage instruction and respond appropriately to missing, conflicting or unclear information.

Competence must be documented and reassessed:

• At intervals determined by the provider’s medicines competency framework.
• Following a medicines error, near miss or identified concern.
• Where the person’s treatment or medicines-support needs change.
• Following a significant change to relevant guidance, equipment or working practice.
• Where the staff member has not performed the task for a prolonged period.

Where a healthcare professional delegates a healthcare activity associated with anticoagulant treatment, the service must obtain and retain clear written information covering:

• The activity being delegated.
• The individual to whom it relates.
• The expected outcome.
• Required training and competence.
• Limits of the care worker’s role.
• Monitoring and review arrangements.
• Who remains professionally accountable.
• Who staff must contact for advice or deterioration.

The provider must not accept a delegated activity unless it can demonstrate that appropriately trained, competent and supervised staff are available and that the activity is consistent with the service’s statement of purpose and insurance arrangements.

10. Documentation and Audit Procedures

To ensure compliance and best practice, {{org_field_name}} implements:

• Medicines administration records must be checked at a frequency proportionate to the risk and service arrangements. Any gap, unexplained code, discrepancy, late entry or conflicting instruction relating to an anticoagulant must be investigated and acted upon without delay.
• Anticoagulant management must be included within the provider’s scheduled medicines-audit programme. Audit frequency must be determined by risk, service size, previous findings and incident trends, with additional audits undertaken where concerns are identified.

• Records must provide a complete audit trail of the medicine offered or administered, the dose, date, time, outcome, identity of the staff member and any reason why the medicine was not taken.
• For warfarin, records must include the current authorised dose, source and date of the instruction, date of the latest INR test where available, next-test date and any communication with the anticoagulation service.
• Changes to treatment must be transcribed or entered only by staff authorised and trained under the organisation’s medicines procedure. A second check must be completed where required by that procedure.
• Telephone instructions must be accepted only in accordance with the organisation’s medicines policy. The caller’s name, role, organisation, date, time, exact instruction, recipient of the instruction and any verification must be recorded.
• Medication errors and near misses must be reported immediately through the organisation’s incident system. The person must be assessed for harm and prompt advice obtained from an appropriate healthcare professional.
• The provider must review incidents for patterns, contributing factors and lessons. Required changes to the personal plan, risk assessment, training, staffing or medicines system must be recorded and implemented.
• Information must be shared in accordance with data-protection and confidentiality requirements, while ensuring that relevant healthcare professionals receive the information necessary to provide safe treatment.

• Incident reporting procedures for medication errors, adverse effects, or missed doses.
• Clear communication with external healthcare providers, ensuring all INR results and dosage adjustments are documented and actioned correctly.

11. Communication, Transfers and Changes to Treatment

The service must maintain clear arrangements for communication between the individual, their representative where appropriate, care staff, the prescriber, supplying pharmacy, anticoagulation service, community nursing service and commissioner.

When anticoagulant treatment is started, stopped, withheld or changed, the manager or authorised person must ensure that:

• The instruction originates from an authorised healthcare professional.
• The current medicines administration record and personal plan are updated promptly.
• Obsolete dosage instructions are clearly cancelled or removed from use while being retained where required for the audit trail.
• Relevant staff are informed before the next scheduled administration.
• The supplying pharmacy and other relevant professionals are informed where necessary.

Following discharge from hospital, transfer between services or a change of care provider, staff must not assume that the previous anticoagulant dose remains current. Medicines must be reconciled against the discharge information, dispensing label and current authorised instructions, and any discrepancy must be resolved before staff administer the medicine.

12. Related Policies

This policy should be read alongside:

• Medication Management and Administration Policy (DCW21)
• Infection Prevention and Control Policy (DCW17)
• Safe Care and Treatment Policy (DCW11)
• Staff Supervision, Training, and Development Policy (DCW27)
• Managing Accidents, Incidents, and Near Misses Policy (DCW24)

• Mental Capacity, Consent and Best-Interests Policy
• Medicines Error and Incident Reporting Procedure
• Hospital Admission, Discharge and Transfer-of-Care Procedure
• Delegated Healthcare Tasks Policy
• Record Keeping, Confidentiality and Data Protection Policy
• Safeguarding Policy
• Duty of Candour Policy

13. Policy Review

This policy will be reviewed annually or sooner if legislation, CIW guidelines, or best practices change. The policy must be reviewed at least annually and sooner following a relevant legislative or national-guidance change, a significant anticoagulant-related incident, an identified medicines-management trend, a safeguarding concern, a recommendation from CIW or another relevant authority, or a material change in service delivery. Changes must be communicated to affected staff and incorporated into training, competency assessment, personal-plan documentation and audit arrangements as appropriate. Information directly affecting an individual’s care must be communicated to the individual and their representative, where lawful and appropriate, in an accessible format.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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