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CH145-Safe Management of Warfarin and Anticoagulant Therapy Policy

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Safe Management of Warfarin and Anticoagulant Therapy Policy

1. Purpose

The purpose of this policy is to ensure the safe, effective, and consistent management of Warfarin and other anticoagulant therapies for the people we support at {{org_field_name}}. Anticoagulants are high-risk medicines due to their potential for causing serious harm if not managed properly. This policy outlines clear procedures for administration, monitoring, record-keeping, and communication with healthcare professionals. It supports Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 by promoting safe care and treatment through proper medicine management, risk reduction, and prevention of avoidable harm.

2. Scope

This policy applies to all staff involved in the care, support, or administration of medication to people receiving Warfarin or other anticoagulants such as Apixaban, Rivaroxaban, Edoxaban, and Dabigatran. It covers registered nurses, care staff, medication technicians, the Registered Manager, and any staff responsible for coordinating or supervising care. It also applies to bank and agency staff when working under the direction of {{org_field_name}}. The policy includes guidance on new admissions, ongoing monitoring, inter-professional communication, and escalation of concerns relating to anticoagulant therapy.

3. Related Policies

4. Medication Risk Classification

Anticoagulants are high-risk medicines because errors in prescribing, administration, monitoring or communication may result in serious bleeding or thromboembolic harm. Warfarin is a vitamin K antagonist with a low therapeutic index and requires regular International Normalised Ratio (INR) monitoring so that the prescribed dose can be adjusted appropriately.

Direct oral anticoagulants (DOACs), including apixaban, rivaroxaban, edoxaban and dabigatran, do not require routine INR monitoring. However, they require appropriate clinical monitoring in accordance with the individual prescription and monitoring plan, including consideration of renal function, and where clinically indicated liver function, full blood count, body weight, age, interacting medicines and bleeding risk.

Staff must understand which anticoagulant the person is prescribed and must follow the monitoring and administration requirements applicable to that specific medicine. Staff must recognise signs and symptoms of bleeding, excessive anticoagulation and thromboembolic events and escalate concerns promptly in accordance with the person’s care plan and clinical advice.

Each person receiving anticoagulant treatment must have an individualised care plan and appropriate risk assessment which identify the medicine prescribed, indication where known, current dose and instructions, monitoring arrangements, relevant risks, action to take if a dose is missed or refused, signs and symptoms requiring escalation, and the healthcare professional or anticoagulation service to contact for advice.

5. Admission and Assessment Procedures

At admission, readmission from hospital, transfer into the service, or commencement of anticoagulant therapy, staff must establish an accurate and current record of the person’s anticoagulant treatment before the care home assumes responsibility for administration.

For a person prescribed warfarin, this must include, where applicable:

For a person prescribed a direct oral anticoagulant, including apixaban, rivaroxaban, edoxaban or dabigatran, staff must establish the medicine, strength, dose, frequency, indication where known, current monitoring arrangements and the healthcare professional responsible for ongoing prescribing and clinical monitoring.

Medicines reconciliation must be completed in accordance with the home’s Medication Management and Administration Policy. Any discrepancy, unclear dose, missing anticoagulation instruction or uncertainty regarding the current prescription must be resolved with an appropriate healthcare professional before staff administer a dose where the correct authorised dose cannot otherwise be established.

The assessment must identify the level of medicines support required, including whether the person self-administers their anticoagulant wholly or partly. Where a person self-administers, an appropriate risk assessment must be completed and reviewed in accordance with the home’s medicines policy.

Consent to care and treatment must be obtained in accordance with Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

A person must be presumed to have capacity unless it is established that they lack capacity. Staff must not assume that a person lacks capacity because of their age, diagnosis, disability, communication needs or because they make a decision that staff consider unwise. All practicable steps must be taken to support the person to understand the relevant information and make the decision.

Where there is reason to doubt the person’s capacity to make a specific decision about their anticoagulant treatment or medicines support, capacity must be assessed in relation to that specific decision and at the relevant time, in accordance with the Mental Capacity Act 2005. Where the person lacks capacity, any decision or action taken on their behalf must comply with the Mental Capacity Act 2005, including the statutory best-interests requirements and consultation with appropriate persons where required. Any applicable health and welfare Lasting Power of Attorney, court-appointed deputy or other lawful authority must be identified and respected within the scope of that authority.

The assessment, consent arrangements, capacity assessment where required, and any best-interests decision must be clearly documented in the person’s records.

6. Care Planning and Documentation

Each person receiving anticoagulant therapy must have an up-to-date and individualised care plan which reflects their current treatment and identified risks.

For a person receiving warfarin, the care plan and associated medication records must identify, as applicable:

The care plan must be reviewed and updated when there is a clinically relevant change, including a change to the warfarin dose, monitoring schedule, target INR, health condition, interacting medicine or identified risk.

The current warfarin dosing instruction must originate from an appropriately authorised prescriber or anticoagulation service. Staff must be able to identify the source and date of the current instruction. Superseded dosing instructions must be clearly marked as no longer current or removed from active use in accordance with the home’s record-management arrangements so that they cannot be mistaken for the current instruction.

Where a dose or other medicine instruction is transcribed onto a MAR chart or another care-home record, transcription must be carried out and checked in accordance with the home’s Medication Management and Administration Policy. Staff must not alter a prescribed dose on their own authority.

For a person receiving a direct oral anticoagulant, the care plan must record the current medicine, strength, dose, frequency, relevant monitoring arrangements, identified bleeding or thromboembolic risks and the healthcare professional responsible for ongoing prescribing and clinical monitoring.

Relevant INR results, dosing instructions, monitoring information and communications affecting anticoagulant treatment must be recorded accurately, clearly and promptly in the person’s records.

Prescription medicines, over-the-counter medicines, complementary or herbal products and supplements that may interact with anticoagulant therapy must be referred to an appropriate healthcare professional or pharmacist for advice before they are commenced where the care home is involved in their use. Relevant advice and resulting changes must be documented.

7. Monitoring and INR Management

Warfarin must be administered in accordance with the person’s current authorised dosing instruction and monitoring plan.

Staff responsible for the person’s medicines must ensure that INR monitoring takes place at the frequency specified by the anticoagulation service, GP or other responsible healthcare professional and must have a system for identifying when an INR test is due or overdue.

Following an INR test, staff must ensure that the result and any revised dosing instruction are obtained, documented and communicated to staff responsible for administering the medicine as soon as practicable and before the revised dose is required.

Staff must not independently calculate, estimate, increase, reduce, omit or otherwise alter a warfarin dose on the basis of an INR result.

Where an INR result or revised dosing instruction is delayed, staff must first establish whether a current authorised dosing instruction remains applicable. Staff must not automatically omit warfarin solely because an expected INR result has been delayed.

Where:

staff must seek timely advice from the anticoagulation service, GP, prescriber, pharmacist, NHS 111 or other appropriate healthcare professional, according to the urgency of the situation, before deciding whether to administer or withhold the dose.

The advice received, including the name or role of the healthcare professional, date, time and instructions given, must be recorded in the person’s records and communicated to the staff responsible for administering the medicine.

A missed, refused, omitted, delayed or incorrectly administered dose must be recorded accurately. Where clinical advice is required, it must be obtained promptly and the advice followed. Staff must not administer an additional or double dose to compensate for a missed dose unless this has been specifically authorised by an appropriate prescriber.

Staff must remain alert to signs and symptoms of bleeding or thromboembolic complications.

Emergency assistance through 999 must be sought where the person’s condition indicates a medical emergency, including suspected stroke, severe or uncontrolled bleeding, vomiting or coughing blood, significant suspected internal bleeding, sudden neurological deterioration, collapse, loss of consciousness or another life-threatening presentation.

For non-life-threatening bleeding, unexplained bruising, suspected adverse effects or other concerns, staff must obtain prompt clinical advice through the person’s GP, anticoagulation service, NHS 111 or another appropriate healthcare professional according to the person’s symptoms and care plan.

Any incident, clinical advice received and action taken must be documented in the person’s records and reported through the home’s incident-reporting system where applicable.

7.1 Direct Oral Anticoagulant Monitoring

Direct oral anticoagulants (DOACs), including apixaban, rivaroxaban, edoxaban and dabigatran, do not require routine INR monitoring and staff must not use an INR result to determine or alter a DOAC dose.

Each person prescribed a DOAC must have an individualised care plan identifying the medicine, strength, prescribed dose and frequency, indication where known, responsible prescriber and relevant clinical monitoring arrangements.

The care home must have arrangements to support completion of monitoring requested by the responsible prescriber or healthcare professional. This may include renal function, full blood count, liver function, body weight and other monitoring according to the medicine prescribed, the person’s age, clinical condition and individual risks.

Staff must not independently interpret laboratory results to alter a DOAC dose. Where a result, change in health condition or instruction raises a concern about whether the prescribed dose remains appropriate, staff must seek advice from the prescriber, GP, pharmacist or other appropriate healthcare professional.

Particular attention must be given to changes which may affect the safety of DOAC treatment, including:

Any change to DOAC treatment must be supported by an authorised prescribing instruction and recorded promptly in the person’s medication records and care plan.

A missed, refused, omitted or additional DOAC dose must be managed in accordance with the instructions for the specific medicine and advice from an appropriate healthcare professional where required. Staff must not assume that missed-dose instructions for warfarin apply to a DOAC, or that instructions for one DOAC apply to another.

8. Safe Administration Practices

Only staff who have been trained, assessed as competent and authorised in accordance with the home’s Medication Management and Administration Policy may administer anticoagulant medicines.

Before administration, staff must apply the home’s medicines-administration procedure and confirm the correct person, medicine, dose, route, time and current authorised instruction, together with any medicine-specific requirements relevant to safe administration.

For warfarin, staff must check the dose against the most recent current authorised warfarin dosing instruction. Staff must never guess, estimate, independently calculate or alter a warfarin dose.

Where the home’s medication procedure requires an independent second check for warfarin or another anticoagulant, that check must be completed and documented in accordance with that procedure.

People receiving warfarin must not routinely be instructed to avoid foods containing vitamin K. Staff must support the person to maintain a reasonably consistent diet and must not impose unnecessary dietary restrictions. Significant planned or unplanned changes in intake of foods containing vitamin K, nutritional supplements or special diets must be communicated to the anticoagulation service, GP, pharmacist or other appropriate healthcare professional where they may affect anticoagulation control.

Staff must also be alert to other food, drink, prescribed medicines, over-the-counter medicines, herbal preparations and supplements that may interact with anticoagulant treatment. Appropriate clinical or pharmacy advice must be sought before staff support the commencement of a non-prescribed product where an interaction may occur.

Anticoagulant tablets must not be crushed, split, dispersed or otherwise altered unless suitability has been confirmed for that specific medicine and formulation by an appropriate pharmacist, prescriber or other authoritative medicines source, and the administration instruction is documented. Staff must not assume that advice relating to warfarin applies to a DOAC or that all DOAC formulations can be altered in the same way.

Staff must record administration immediately after the medicine has been administered in accordance with the home’s medicines procedure. Refusal, omission or other non-administration must be recorded using the appropriate code or entry together with any required explanatory information and escalation.

Appropriate hand hygiene and infection-prevention procedures must be followed in accordance with CH17 – Infection Prevention and Control Policy.

9. Communication with Health Professionals

{{org_field_name}} must maintain effective communication with the healthcare professionals involved in each person’s anticoagulant treatment, including the GP, prescriber, anticoagulation service, pharmacist, community nursing team and hospital team where applicable.

Staff must promptly communicate relevant concerns, including:

Where an INR test has been undertaken, staff must ensure that the result and any revised dosing instruction are obtained within the timeframe necessary for safe continuation of treatment. Where a result or instruction has not been received when expected, staff must actively follow this up and use the escalation procedure in Section 7 where the correct dose cannot be safely established.

When a person is admitted or readmitted following hospital treatment, or transfers between services, anticoagulant treatment must be included in medicines reconciliation. Staff must identify and resolve any discrepancy between the discharge prescription, previous medication records, current MAR chart, anticoagulation record and any other dosing instruction before administering a dose where the discrepancy affects the safe administration of the medicine.

Where responsibility for monitoring, prescribing or administering the anticoagulant is shared between organisations, the person’s records must clearly identify who is responsible for each element of treatment and how relevant information will be communicated.

All clinically relevant communications and instructions must be documented promptly in the person’s records and communicated to staff who need the information, including through handover arrangements where appropriate.

10. Staff Training and Competency

All staff responsible for anticoagulant administration must complete accredited medication training and competency assessments annually. Additional specific training on anticoagulant therapy, Warfarin management, and identifying complications must be provided and documented. New staff are shadowed by experienced and competent colleagues until assessed as safe to administer independently. Ongoing supervision and spot checks are carried out by the Registered Manager or Deputy Manager to ensure consistent practice.

11. Record-Keeping and Audit

Accurate records of Warfarin doses administered, INR results, communication with professionals, missed doses, and adverse events must be maintained at all times. Records must be legible, signed, and dated. Weekly audits of MAR charts and anticoagulant care plans are conducted by senior staff to check compliance and detect discrepancies. Any errors are investigated in accordance with CH24 – Management of Accidents, Incidents, and Near Misses Policy. Outcomes are discussed during staff meetings and used for learning and improvement.

12. Responding to Medication Errors, Adverse Events and Suspected Harm

Any suspected overdose, additional dose, underdose, omitted dose, administration error or adverse reaction involving an anticoagulant must be taken seriously and assessed promptly.

Staff must first assess the person’s immediate condition.

Where there are signs or symptoms of a medical emergency, including severe or uncontrolled bleeding, suspected stroke, significant internal bleeding, collapse, loss of consciousness, severe breathing difficulty or another life-threatening presentation, staff must call 999 immediately and provide first aid or emergency support within their competence.

Where there is no immediate life-threatening presentation, staff must promptly seek appropriate clinical advice according to the circumstances. This may include contacting the anticoagulation service, GP, out-of-hours service, pharmacist or NHS 111. Staff must provide accurate information about the medicine, strength, prescribed dose, dose actually taken or omitted, timing, relevant INR information where applicable, other medicines and the person’s current condition.

Staff must follow the clinical advice received and must document:

Staff must not administer a compensating or double anticoagulant dose unless specifically instructed to do so by an appropriate prescriber.

All anticoagulant medication errors and near misses must be reported through the home’s incident-reporting procedure and reviewed in accordance with CH24 – Management of Accidents, Incidents and Near Misses Policy.

The Registered Manager or delegated responsible person must consider whether the incident meets the criteria for:

A medicines error does not, by itself, automatically require notification to the Care Quality Commission. A CQC notification must be made where the incident or its consequences meet the applicable statutory notification criteria.

{{org_field_name}} must act in an open and transparent way with people receiving care and relevant persons in relation to care and treatment. Where an anticoagulant-related incident meets the statutory definition of a notifiable safety incident under Regulation 20, the formal Duty of Candour procedure must be followed as soon as reasonably practicable, including notification of the relevant person, provision of a truthful account of the known facts, an apology, reasonable support, appropriate further enquiries, written follow-up and maintenance of the required records.

Following an anticoagulant-related incident, the Registered Manager or delegated responsible person must ensure that an appropriate review or investigation is completed, proportionate to the seriousness of the event. The person’s risk assessment and care plan must be reviewed where necessary, and identified learning or corrective actions must be implemented and monitored.

13. Efficient Management by {{org_field_name}}

{{org_field_name}} supports the safe management of anticoagulant therapy through:

These arrangements are designed to reduce the risk of missed, omitted, delayed or incorrect doses, identify anticoagulant-related risks promptly, support appropriate escalation and provide evidence that medicines are being managed safely.

14. Policy Review

This policy will be reviewed annually or sooner if required by changes in legislation, best practice guidance, or following a related incident.

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}}
Copyright © {{current_year}} – {{org_field_name}}. All rights reserved.

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