HSSIB investigation report: Medication not given: anticoagulation before and after a procedure (13 March 2025)

Summary

This is the second in a series of investigations exploring why medications intended to be provided to patients were not provided. Patients who need medications can suffer harm if these are not provided.

This investigation explored the systems and processes in place to support staff when a patient who is usually taking an anticoagulant undergoes a procedure. An anticoagulant is a medication that reduces the ability of a patient’s blood to clot. The investigation also explored the role played by electronic prescribing and medication administration (ePMA) systems and electronic patient record (EPR) systems in supporting care in this area.

Content

The investigation explored a patient safety event involving a man aged 87 who was admitted to hospital. He usually took an anticoagulant medication (apixaban) to reduce the risk of having a stroke. A stroke is a serious medical condition that occurs when the blood supply to part of a person’s brain is lost. 

The patient was taken to hospital with shortness of breath and nose bleeds. He was transferred from the emergency department to a medical ward while waiting for a procedure. The medical team paused the patient’s regular apixaban, initially because of his nose bleeds. The apixaban continued to be paused while the patient was waiting for his procedure. However, delays to the procedure taking place meant that apixaban was not given for a total of 10 days. After the procedure, the apixaban was not restarted as intended. Two days after the procedure the patient had a stroke and later died.

Medical staff needed to make informed prescribing decisions, balancing the patient’s risk of developing a blood clot, his everyday risk of bleeding, with the risk of bleeding from the required medical procedure. The investigation explored the range of complex, dynamic and interacting clinical and wider hospital factors that led to the difficulties in managing the patient’s anticoagulation.

Findings

• The patient’s apixaban was appropriately paused in the emergency department.
• Past clinical information about the patient that would have supported anticoagulant risk assessments was not easily available to staff.
• Variations in the hospital care processes supported some working practices, but created uncertainty about when the patient’s procedure could happen. This made dynamic clinical decision making challenging.
• A lack of specialist nursing and/or administrative support limited the ability for respiratory referrals to be followed up by the respiratory team in a timely way.
• There was no reassessment of the ongoing decision to pause the patient’s apixaban when the procedure did not happen as expected.
• It was clear to staff that the patient’s apixaban was paused on the ePMA system, but the system did not prompt staff to re-review the paused apixaban.
• An assessment of the risks and benefits of pausing the patient’s apixaban was not documented which prevented a shared understanding of the decision for other staff involved in the patient’s care.
• Workforce challenges created conditions on the acute general medical ward that limited the resources available to follow up on the patient's medication status and delayed discussions around the patient’s transfer to the respiratory ward.
• A mismatch between demand and capacity within the respiratory service prevented the patient being transferred to the respiratory ward or receiving regular specialty respiratory input while he was being cared for on the acute general medical ward.
• Some local clinical guidance available to staff on the management of patients’ anticoagulant medication was overdue for a review and did not reflect updated national guidance.
• Local clinical guidance was sometimes hard to access using the Trust’s computer systems and some staff were unaware of relevant guidance that was in place.
• There were no cues in the post-procedure documentation to prompt staff to consider restarting the patient’s anticoagulation medication.
• Phased implementation of the Trust’s EPR system meant that sometimes staff were duplicating entries across paper and electronic record systems.

Local level learning prompts for acute hospitals

HSSIB investigations include local-level learning where this may help organisations and staff identify and think about how to respond to specific patient safety concerns at the local level. The following prompts are provided by HSSIB to help acute hospitals to improve the safety of patients who are taking anticoagulation medication who need to have a procedure. These prompts may also be useful in other settings.

Anticoagulant prescribing

• How does your organisation support staff to identify and document decision making at critical decision points where anticoagulation should be reviewed?
• How does your patient record system support staff to document and clearly display the rationale behind any decision to pause anticoagulant medication?
• Does your organisation have systems and processes in place that support regular risk assessment of anticoagulants that have been paused?
• Does your organisation have a process for ensuring that guidelines that cross-refer to other relevant guidelines are reviewed together to ensure they provide consistent advice?
• How do you ensure that all members of the multidisciplinary team with relevant expertise are included in clinical guideline reviews?
• Does your organisation have processes in place to ensure that when new evidence on newer anticoagulants becomes available it is considered for inclusion in local guidance as soon as possible?
• How does your organisation support staff to find and readily access anticoagulation related guidelines?

Care processes supporting inpatients on anticoagulants

• Do your organisation’s bed management meetings include a review of patients who have been waiting more than 24 hours for transfer to a specialty ward?
• Does your organisation have effective processes in place to ensure inpatients accepted by a speciality, but awaiting a specialty bed, receive a specialty review on a regular basis?
• Does your organisation have a process in place for the prioritisation of inpatient transfer to specialty services?
• Does your organisation have a process in place for the prioritisation of inpatients who need investigations (including imaging) and procedures?
• Do your organisation’s post procedure processes include a prompt to review anticoagulation?

EPR/ePMA systems supporting anticoagulation

• Does your organisation ensure it is easy for staff to access information in patients’ records relevant to decision making about anticoagulant medication?
• Does your ePMA system identify patients with paused time-critical medication that may warrant a review?
• How does your organisation consider factors relating to equipment which may affect the successful implementation of EPR/ePMA systems?