Qual Saf Health Care 19:295-297 doi:10.1136/qshc.2009.035089
  • Original research

A baseline study of anticoagulant management in UK hospitals

Press Release
  1. Karin Lowson3
  1. 1Cardiff School of Nursing and Midwifery Studies, Caerleon Campus, St Cadocs Hospital, Caerleon, UK
  2. 2Cardiff School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK
  3. 3York Health Economics Consortium, Market Square, University of York, Vanbrugh Way, Heslington, York, UK
  1. Correspondence to Dr Annette Lankshear, Cardiff School of Nursing and Midwifery Studies, Caerleon Campus, St Cadocs Hospital, Caerleon NP18 3XR, UK; lankshearaj{at}
  • Accepted 30 April 2010
  • Published Online First 2 August 2010


Objectives To undertake a baseline study of the management of anticoagulants in order to allow later comparison of the impact of the National Patient Safety Agency (NPSA) patient safety alert (including a new patient held record) published in April 2007.

Methods A multimethod study comprising semistructured interviews in 20 acute trusts and a telephone/email survey of general practitioners (GPs).

Results The authors found a high degree of consensus concerning a number of problems in the management of anticoagulation services. Consultant haematologists and chief pharmacists expressed concern about the level of competence of junior medical and nursing staff and the quality of patient discharge from general inpatient wards. Patients were regularly discharged before being stabilised on Warfarin, pre-discharge information was not always given, patient-held records were not reliably completed nor follow-up arrangements made. At the ward level, there was some confusion about the responsibility for completing the yellow book on discharge and little awareness of the role of GPs in providing a monitoring service. GPs were largely dissatisfied with the quality of discharge information.

Conclusion The baseline data present a significant cause for concern in the management of warfarin prior to the publication of the NPSA safety alert.


  • Funding This research was funded by the National Patient Safety Agency.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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