Preparing for the worst: A key for better anticoagulation management

Case studies are useful for studying complex work systems when direct data collection about rare and challenging situations is not practical using in situ field methodologies, such as observations or archival studies, such as review of medical records. In healthcare organizations, careful examination of challenging situations can guide appropriate responses to the worst situations. The purpose of this study is to identify characteristics of challenging situations in the management of oral anticoagulation and to understand opportunities for work interventions. Managing oral anticoagulation with warfar in is challenging because of the narrow therapeutic range. The therapy can easily lead to harm both from excessive and insufficient anticoagulation. We collected 32 memorable cases that include description of complex patients and their anticoagulation management by interviewing 22 staff members from six VA affiliated anticoagulation clinics. Data revealed that complex cases were typically patients who could not be reached easily and patients who could not change their lifestyle as required by the treatment. Memorable cases also included tensions with other clinicians. Health information technologies can be designed to improve the quality of anticoagulation management by supporting follow-up and increasing adherence. Case management roles and structures at anticoagulation clinics can be created to support complex patients and improve anticoagulation therapy.