Warfarin directions

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Dee Hunnisett_Dritz
Dee Hunnisett_Dritz's picture
Last seen: 1 year 2 months ago
Joined: 04/07/2023 - 14:00
Warfarin directions

ISMP suggested I reach out to this message board
Has any one done any work or had experiences with regard to best practice for warfarin directions for ambulatory prescriptions and therefore the Medicine bottle label? I would appreciate a discussion.
We are in conflict on how to reduce the risk for error and I have been looking for a standard to help us to come to a consensus.
Example: I prefer, and historically the practice has been to quote a range of tablets in the prescription directions with added instructions, example as follows:
"Take half a tablet to 2 tablets by mouth once a day. Your doses will change per the INR value. Follow the instructions given to you."
When the patient comes to take the dose from the bottle, the range on the label forces a ' stop and think ' because the bottle does not tell them how many tablets to take. They know instructions are given by the anticoagulation clinic.
The Anticoagulation Clinic prefer to update the ambulatory prescription entry in the medical record (we use Epic) with the most up to date directions. They update the ambulatory medication entry every time an INR results for healthcare awareness, but don't send a repeat prescription to the pharmacy, therefore the prescription bottle is never updated.
However, when it comes time to get a new Prescription sent to pharmacy the reorder button from the ambulatory entry is the easiest option and most frequently used and the most recent dosing will be included and will appear on the tablet bottle.
Example " take 7.5 mg Mondays Wednesdays and Fridays and 5 mg all other days or as directed. "
The INR is checked frequently, and this dosing has potential to be inappropriate at the next INR check. The inappropriate directions would remain at the pharmacy for all refills and therefore could remain on the bottle until the Rx expires at the pharmacy in 1 year and new Rx is issued again with shortlived directions because of a repeat process.
I am concerned because this will be what the patient sees every time they go to take a dose. The bottle may accompany them to other healthcare admissions etc etc
Clearly, 'use as directed' is not an option - we are all agreed on that.
I would really like to explore how this is handled in your world
I appreciate your input and value your expertise and experience
Kind Regards