Qualidigm Authors National Study on Adverse Events

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Warfarin-Related Adverse Events Remain Common in Hospitalized Patients

A new study published December 14, 2015 in the Journal of Hospital Medicine, “Predictors of Warfarin-Associated Adverse Events in Hospitalized Patients: Opportunities to Prevent Patient Harm,” found that adverse events related to warfarin, a drug used as an anticoagulant (blood thinner), remain common in hospitalized patients. Qualidigm, the mission-driven healthcare consulting company based in Wethersfield, Conn., with the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare & Medicaid Services (CMS), and other national leading institutions, conducted the study.

The researchers used medical record data of Medicare patients 65 and older from the Medicare Patient Safety Monitoring System, the nation’s largest randomly selected medical record abstraction-based database designed for patient safety tracking.

The study, which was funded through the AHRQ, assessed the frequency of international normalized ratio (INR) testing to monitor the effectiveness of warfarin, and its relationship to over-anticoagulation and warfarin-related adverse events.

“The results of this study show that the INR was not always monitored daily, and lack of daily monitoring was associated with over-anticoagulation and bleeding adverse events,” said Mark Metersky, M.D., lead author of the study and also a Professor of Medicine in the Division of Pulmonary and Critical Care Medicine at the University of Connecticut School of Medicine. “The observed lapses in daily INR monitoring may in part be due to the absence of evidence or guidance on how often the INR should be monitored in patients receiving warfarin in the hospital. We hope that the evidence of a relationship between less than daily INR monitoring and bleeding events will lead to improved practices and safer care for hospitalized patients.”

“Improving patient safety in the hospitals starts with determining the root causes for adverse events,” said Qualidigm president and CEO, Tim Elwell. “Qualidigm has been working on patient safety since 2001. We are pleased that this study has revealed yet another evidence-based practice that can improve care for hospitalized patients.”

Since the Institute of Medicine’s landmark article, “To Err is Human: Building a Safer Health System” revealed the staggering number of patients who die in U.S. hospitals each year due to the “nation’s epidemic of medical errors,” wide-ranging efforts have been implemented by a multitude of America’s healthcare stakeholders to improve patient safety, care coordination and processes, health outcomes and cost efficiencies.

Nationally, AHRQ has developed a patient safety toolkit for hospitals to use to prevent pressure ulcers, and is participating in the national effort in concert with the American Hospital Association to prevent catheter-associated urinary tract infections. AHRQ is also a key participant in the Federal Partnership for Patients program, which aims to demonstrate improvements in patient safety by reducing preventable adverse events among all patients by 40 percent from 2010 to 2013.

A link to the online version of the article can be found here.

Mark Metersky is the lead and corresponding author for this study and a Qualidigm consultant. Co-authors include: Yun Wang, Ph.D., (Harvard School of Public Health and Qualidigm consultant); Noel Eldridge, M.S., (AHRQ); Lisa Jaser, Pharm.D. (Griffin Hospital); Robert Bona, M.D. (Frank H. Netter MD School of Medicine); Sheila Eckenrode, R.N. and Anila Bakullari, B.S., (Qualidigm); Mary Andrawis, Pharm.D. , M.P.H. (CMS); David Classen, MD, (United States Department of Health and Human Services); and Harlan M. Krumholz, MD, SM. (Yale University School of Medicine).

About Qualidigm:
With its corporate headquarters in Wethersfield, Conn. and offices in Dover, NH; Barre, VT; and Providence, RI, Qualidigm's mission is to improve the quality, safety, and cost-effectiveness of healthcare through transformational change. Qualidigm provides consulting services to public and private sector clients nationwide. These services include consulting, data analysis, health information technology, patient safety, quality improvement, and utilization review. Qualidigm is part of a team that is serving as the Medicare Quality Innovation Network Quality Improvement Organization (QIN-QIO) under contract with the Centers for Medicare and Medicaid Services for New England. Qualidigm is also a Patient Safety Organization (PSO) as designated by the State of Connecticut. http://www.Qualidigm.org

About AHRQ:

The Agency for Healthcare Research and Quality’s mission is to improve the quality, safety, efficiency and effectiveness of healthcare for all Americans. As one of 12 agencies within the Department of Health and Human Services, AHRQ supports research that helps people make more informed decisions and improves the quality of healthcare services. http://www.ahrq.gov


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