5PSQ-010 Identification of incorrect dosing of direct oral anticoagulants: an important intervention to improve patient safety

Abstract

seven-item questionnaire: prescription, monitoring, pump use, clarity of prescription, nurse skills and presence of a painreferent (specialised nurse). The information was collected in the care unit using PCA between June and September 2021. Results Seven department health executives were interviewed. Concerning the prescription: five departments use a computerised prescription, none include dilution information, and programming details are added by the prescriber because there is no prepared protocol. Two services use a paper prescription that is also the follow-up paper: they contain dilution information but not the background dose. Five services carry out the follow-up with a paper follow-up sheet, which differs according to the service, and two services use written computer transmissions. Concerning the other items: there is a lack of training sessions about the PCA pump use, only one service had a recent course by the company. Conclusion and relevanceThe assessment showed a disparity in the method of prescription and monitoring. It appears that essential data are missing, data which are necessary to have a complete prescription. It would be interesting to work on a computer protocol making it possible to simplify the prescription (basic dose, bolus, inter-dose, etc.), as well as to propose a single paper prescription for non-computerised services. A working group comprising representatives of the pharmacy department, prescribers from the care units concerned, health executives and pain-adviser nurses has been set up to work on this issue with the objective of improving patient care.