5PSQ-058 Medicines reconciliation of home oral anticoagulants upon admission – are we doing it well?

<h3>Background and Importance</h3> In March 2023, our hospital Thrombosis Committee approved a protocol for the management of oral anticoagulants (OACs) in patients who were taking them at home at the point of hospital admission. <h3>Aim and Objectives</h3> To evaluate compliance with the protocol and detect medication errors (MEs) as a result of non-compliance. <h3>Material and Methods</h3> This was a 2 month cross-sectional observational study (December 2023 to January 2024). The inclusion criteria were patients with low molecular weight heparin (LMWH) prescribed in hospital and who were on OACs at home. The medicines reconciliation process using the new protocol was carried out in these patients. <h3>The main variables were:</h3> Percentage of patients where the protocol was followed, which establishes to stop vitamin K antagonist (VKA) and start therapeutic LMWH dose when the INR is less than 2, except for patients with mechanical prosthesis or venous or arterial antiphospholipid syndrome. In patients on direct-acting oral anticoagulants (DOACs), it was recommended to maintain home anticoagulation. In those patients with MEs detected, it was considered that the protocol was not followed. Percentage of patients with MEs, classified as MEs related to supratherapeutic dosing, subtherapeutic dosing or delayed administration of LMWH. Data were collected from our hospital electronic medical records. <h3>Results</h3> A total of 62 patients were analysed, 48.4% with home DOACs and 51.6% with home VKA. 37.1% patients were compliant with the protocol and 62.9% were not compliant. The reasons for non-compliance were: 20.5% patients had DOACs stopped to start on LMWH instead of continuing DOACs, 5.1% continued VKA instead of being stopped to start on LMWH and 74.4% were MEs. Of these, 37.9% were MEs due to supratherapeutic dosing, 44.8% due to subtherapeutic dosing and 17.3% due to delayed administration of LMWH. None of the patients with MEs experienced clinical complications. <h3>Conclusion and Relevance</h3> There was a low compliance with the protocol, which was notified to the Thrombosis Committee for review. Additionally, there was a high proportion of MEs detected. MEs due to subtherapeutic dosing were found to be the most frequent. <h3>References and/or Acknowledgements</h3> <h3>Conflict of Interest</h3> No conflict of interest