Identifying safety problems in the General Practice – analysis of the treatment process of oral anticoagulation therapy
DOI: 10.3238/zfa.2009.0148german translation / full article
Background: Oral anticoagulants (OAC) are high alert medications and thus relevant to safety in general practice. In an explorative retrospective observational study the process of treatment was examined for safety gaps, medication errors, interaction risks and contraindications.
Methods: A model of the long-term treatment process was developed using the parameters documentation, therapy decision, patient participation and monitoring strategy. Using 3 international guidelines, 30 process indicators were generated to define safe oral anticoagulation treatment. Data collection was via chart reviews and interviews with patients and general practitioners (GP). Detected irregularities were checked for potential safety risks.
Results: Sixteen GP recruited 100 patients taking OAC. In all practices treatment routines were established, but safety gaps were identified mainly in documentation, and patient participation and knowledge. The target INR-range was not documented in the records of 81 patients; the current medication dose was missing in the records of 55, and an OAC warning was neglected in 70 cases. Thirty-six patients were not informed about the risks and peculiarities of OAC therapy. Contraindications were ignored in 2 cases and interaction risks in 18. Three patients received intramuscular injections. Eighty-seven patients received INR-controls at least every 4 weeks, but in about 30 % of these the reaction to abnormal INR-results was inappropriate.
Conclusions: Room for improvement exists in monitoring, documentation quality and patient involvement. Structured documentation of important process steps for OAC use and the specific involvement of patients seem sensible to increase treatment safety. However, the effectiveness of these actions should be tested in controlled trials.