title: Implementation of an order set to adhere to national patient safety goals for warfarin therapy.
abstract: BACKGROUND
  In 2009, The Joint Commission mandated full compliance with National Patient Safety Goal (NPSG) 03.05.01 to reduce the likelihood of patient harm associated with anticoagulant therapy.
  
  
  METHODS
  We conducted a retrospective chart review of inpatients receiving warfarin at Methodist Hospital pre and post implementation of a warfarin order set between January 2008 and July 2011. The primary endpoint of this study was overall adherence to laboratory monitoring. Secondary endpoints included compliance with individual laboratory parameters, percentage of patient educational sessions completed prior to discharge, and percentage of appropriate follow-up arrangements documented on discharge.
  
  
  RESULTS
  A total of 707 patients were assessed. Overall adherence to laboratory monitoring parameters significantly improved from 71.8% to 87.5% (odds ratio [OR], 2.76; 95% CI, 1.87- 4.07; P < .001). Additional improvements were seen in patient education prior to discharge, and appropriate follow-up arrangements were documented at discharge.
  
  
  CONCLUSIONS
  This analysis demonstrates that implementation of an order set assists in adherence to policies and procedures designed to address the NPSG 03.05.01. Additionally, pharmacy involvement in monitoring, educating, and arranging for follow-up may lead to successful completion of these parameters.
authors.affiliation: Clinical Pharmacist, Internal Medicine, Indiana University Health, Methodist Hospital, and Assistant Professor, Department of Pharmacy Practice, Butler University College of Pharmacy and Health Sciences, Indianapolis, Indiana;
authors.forename: Sarah
authors.initials: S
authors.lastname: Nisly
authors.affiliation: Clinical Pharmacist, Internal Medicine, Indiana University Health, Methodist Hospital;
authors.forename: Erin D
authors.initials: ED
authors.lastname: Shiltz
authors.affiliation: Pharmacy Practice Resident, UC Health, University Hospital, Cincinnati, Ohio;
authors.forename: Vanessa
authors.initials: V
authors.lastname: Vanarsdale
authors.affiliation: Pharmacist, Wabash General Hospital. Mt. Carmel, Illinois. Corresponding author: Sarah Nisly, PharmD, BCPS, Butler University College of Pharmacy and Health Sciences, 4600 Sunset Avenue, Indianapolis, IN 46208; phone: 317-962-3410; fax: 317-963-5397; e-mail: snisly@butler.edu.
authors.forename: Jordyn
authors.initials: J
authors.lastname: Laughlin
keywords: National Patient Safety Goal; follow-up; laboratory monitoring; warfarin