Selection of opportunities for improvement
Incompleteness of anticoagulation therapy monitoring form may result in inappropriate
adjustment of anticoagulation dosage regime and lead to undesirable side effects or
under treatment. This study aimed at improving the documentation of heparin and
warfarin monitoring forms in surgical wards of Kuala Lumpur Hospital (KLH).

Key Measures for improvement
Our standard is 80% completeness of the heparin and warfarin monitoring forms for
all cases commenced in the surgical wards. This standard was agreed between
pharmacists and surgeons during the study proposal presentation.

Process of gathering information
An initial audit on documentation for all patients treated with heparin and warfarin was
carried out and its completeness was determined. It was a cross sectional study using
universal sampling with calculated sample size of 33 cases in each phase. New cases
were identified by clinical pharmacists in-charge of surgical wards and data was
retrieved from heparin and warfarin forms and counterchecked with patient’s case
note. Data collections were carried out 3 months in each phase.

Analysis and Interpretation
Verification study revealed only 58.8% of the monitoring forms were filled completely.
The contributing factors include difficulty in interpreting the existing monitoring form
(35%), unavailability of anticoagulant administration guide (34%) and inexperienced
healthcare providers in terms of documentation (15%).

Strategy for Change
In phase 1 study, existing heparin and warfarin monitoring forms were revised based
on consensus with surgical team apart from developing new heparin and warfarin
administration and monitoring protocol followed by continuous education sessions.
As for phase 2 study, we further improvised the heparin and warfarin monitoring form
based on end users feedback. Final version of the form were printed in pink and
displayed in all surgical wards. Clinical pharmacists were acknowledged as part of the
orientation team members for all junior doctors attached in surgical wards.
In phase 3 study, heparin and warfarin monitoring forms were successfully registered
under KLH Quality Unit with MS ISO 9001:2015.

Effects of Change
The percentage of completeness of both forms improved from 58.8% to 68.7% and
further increased to 80.2% following phase 2 study. We successfully achieved our
standard in post phase 2 study with ABNA of -0.2%. Upon registration as an ISO
document, the percentage of completeness rose to 89.8% with ABNA of -9.8%.
Improvement in heparin and warfarin documentation not only aid surgeons to monitor
patient outcome but also prevent unnecessary adverse effects and medication errors.

The Next Step
The way forward will be to improve documentation compliance to 100% completeness.
The findings from this study merits adoption of remedial measures to other major
government hospitals especially those with vascular sub-specialty service.