Reducing Anticoagulant Related Adverse Events; Redesigning Anticoagulant Management Using Six Sigma Methodology

Since 1999, anticoagulant therapy was one of the top three causes of adverse events. A Six Sigma methodology was used to evaluate medication use processes. Evidence-based solutions tied to identified root cause analyses were implemented and internal outcome measurement re-enforced the need to change and maintain a new standard of care.

This case study is part of the Illinois Hospital Association's annual quality awards. Each year, IHA recognizes and celebrates the achievements of Illinois hospitals in continually improving and transforming health care in the state. These hospitals are improving health by striving to achieve the Triple Aim--improving the patient experience of care (including quality and satisfaction); improving the health of populations; and reducing the per capita cost of health care.

Award recipients achieve measurable and meaningful progress in providing care that is:

• Safe
• Timely
• Effective
• Efficient
• Equitable
• Patient-centered

(The Institute of Medicine's six aims for improvement.)