Multidisciplinary plan multiplies teaching

Patients hear warfarin instruction once and again

Education about warfarin, a drug that prevents clot formation, is important because it is the leading drug involved with adverse drug events year after year, says Steve Pickette, RPH, assistant director of Pharmacy Clinical Services at Sacred Heart Medical Center in Spokane, WA.

"The drug is dangerous even when taken properly. At best, you are looking at a 5%-per-year event rate, which is high, and goes up dramatically if you are not taking it appropriately," he says. People who take too little of the medication are more likely to have a stroke, and those who take too much are more likely to bleed internally.

That’s why the pharmacy department at Sacred Heart has implemented a mandatory interdisciplinary education program for everyone discharged home on the medication. If patients are discharged to a nursing home, the education is not mandatory. The policy was changed from education upon physician request when a quality assurance audit revealed that only 60% of patients on warfarin who were being discharged home received teaching because physicians were forgetting to order it.

Now when the pharmacy department receives an order for warfarin therapy, the pharmacist that processes the order screens the computer system looking for an intervention note attached to the patient’s profile. If there isn’t, they make sure one is added, says Pickette.

"We have clinical pharmacists on each unit of the hospital who receive these intervention notes from a patient profile. They are printed every hour," he says. They also are made aware of the need for teaching during their own profile reviews or upon a nurse’s request.

When a patient is identified as a candidate for warfarin education, a combination of teaching strategies is used. Verbal instruction is important and usually is given by the physician first. "The first question we ask when we walk into the room is, What has your doctor told you about this medication?’ Of course, the physician has educated the patient about it and explained how it fits into their therapy as well," says Pickette.

The pharmacist covers the fact that warfarin is an important part of the patient’s therapy. Also covered are the things patients must do to reduce the risks of an adverse event, including:

Taking the medication as ordered.

Patients are told to set up a system that reminds them when to take the medication because doses cannot be missed or doubled.

Reporting any signs of bleeding.

Patients learn to look for the signs that would indicate internal bleeding. These include black, tarry stools, bleeding of the gums, and bruising.

Understanding adverse drug interactions.

"Warfarin interacts with more medications than any other drug," says Pickette. Patients are told that it is their responsibility to check with their physician before taking any medication, including over-the-counter purchases. They also are told about food and drug interactions and warfarin’s interaction with alcohol.

A dietitian covers dietary restrictions with the patient. The pharmacy computer system prints a list of all patients on warfarin for the dietitian, says Pickette. The nurse also is involved in the education by making sure that patients watch the video on warfarin following the pharmacist’s teaching. Also, nursing reinforces what is taught by pharmacy up to the time of discharge, says Pickette. A booklet on warfarin is given to each patient.

It’s important to involve several disciplines in the education process because it helps to emphasize the importance of what is being taught and provides opportunities for patients to hear the message several times. "A second reason is that we all bring our expertise to the teaching," says Pickette.


For more information about incorporating multi-disciplinary instruction into Warfarin teaching plan, contact:

  • Steve Pickette, RPH, Assistance Direct, Pharmacy Clinical Services, Sacred Heart Medical Center, Attention Pharmacy Department, W. 101 Eighth Ave., Spokane, WA 99220-4045. Telephone: (509) 474-3244. E-mail: