1. NEWSMAY 2015
Updates and reminders:
• Meditech Monthly Downtime:
May 20th, 0230 – 0530
Physician Help Desk:
Phone: 689-5432 or x35432
Atrium hours: Monday-Friday 8:00 a.m.–5:00 p.m.
Rounding Times are 9:00–10:00 a.m.
ON CALL support for nights and weekends
for CPOM issues and questions
Double Trouble –
Inappropriate Dual
Anticoagulant Therapy
Recently we have seen an upswing in the number
of medication errors involving oral anticoagulants.
Examples of these errors include:
• Starting apixaban (Eliquis) on a patient with
concurrent subcutaneous heparin
• Continuing warfarin (Coumadin) on admission
when INR is supratherapeutic
Anticoagulants are inherently high-risk medications
that can result in serious patient safety events.
Whether you are a prescriber, pharmacist, or
nurse, there are several steps you can take to
ensure proper use of these drugs:
• If a patient takes warfarin, check INR results
before ordering / verifying / administering
any anticoagulant
• Questioning anytime multiple anticoagulants are
prescribed
• Novel oral anticoagulants take effect much
sooner than warfarin; when switching between
anticoagulants, time the doses appropriately
(Table 1 on right)
Table 1: Dose timing on anticoagulant switch
Converting From:
Enoxaparin
Fondaparinux
Dabigatran
Rivaroxaban
Apixaban
Warfarin
Converting From:
Heparin (IV)
Heparin (SQ)
Fondaparinux
Dabigatran
Rivaroxaban
Apixaban
Warfarin
Converting From:
Heparin (IV)
Heparin (SQ)
Enoxaparin
Dabigatran
Rivaroxaban
Apixaban
Warfarin
Converting From:
Heparin (IV)
Heparin (SQ)
Enoxaparin
Fondaparinux
Rivaroxaban
Apixaban
Warfarin
Converting From:
Heparin (IV)
Heparin (SQ)
Enoxaparin
Fondaparinux
Dabigatran
Apixaban
Warfarin
Converting From:
Heparin (IV)
Heparin (SQ)
Enoxaparin
Fondaparinux
Dabigatran
Rivaroxaban
Warfarin
Converting From:
Heparin (IV)
Enoxaparin
Fondaparinux
Dabigatran
Rivaroxaban
Transitioning To Heparin (IV or SQ)
Initiate at the time of the next scheduled dose
Discontinue Warfarin and start Heparin when INR is
below the therapeutic range
Transitioning to Enoxaparin
Initiate as the same time of discontinuation of the heparin continuous
infusion
Initiate at the time of the next scheduled dose
Discontinue Warfarin and start Enoxaparin when INR is below the
therapeutic range
Transitioning to Fondaparinux
Initiate as the same time of discontinuation of the heparin continuous
infusion
Initiate at the time of the next scheduled dose
Discontinue Warfarin and start Fondaparinux when INR is
below the therapeutic range
Transitioning to Dabigatran
Initiate as the same time of discontinuation of the heparin continuous
infusion
Initiate at the time of the next scheduled dose
Discontinue Warfarin and start Dabigatran when the INR is <2.0
Transitioning to Rivaroxaban
Initiate as the same time of discontinuation of the heparin continuous
infusion
Initiate at the time of the next scheduled dose
Discontinue Warfarin and start Rivaroxaban when the INR is <3.0
Transitioning to Apixaban
Initiate as the same time of discontinuation of the heparin continuous
infusion
Initiate at the time of the next scheduled dose
Discontinue warfarin and start Dabigatran when the INR is <2.0
Transitioning to Warfarin
Bridge Therapy: Discontinue after a minimum of 5 days duration and
achievement of an INR >2.0 (Both criteria must be met).
Based on renal function, start warfarin a certain number of days
before discontinuing dabigatran: CrCl ≥50 mL/min = 3 days ; 30-50 mL/
min = 2 days; 15-30 mL/min = 1 day; <15 mL/min, no recommendations
can be made.
At the next scheduled dose of the oral anticoagulant, discontinue all oral
anticoagulants and begin bridge therapy with parenteral anticoagulant,
begin warfarin, and continue the parenteral anticoagulant until the
INR reaches an acceptable range.

2. 5/2015
New Changes Coming to Ultra Sound Order Entry Process
The “US Abdomen (USI)” order now contains
required information:
The “US Abdomen RUQ (USI)” now contains
additional information:
The “US Abdomen Limited (USI)” order now contains
required information:
REQUIRED
REQUIRED
C O M I N G I N M I D M AY