Using our advice
This resource supports healthcare professionals (HCPs) in taking action to promote the safer use of DOACs. It provides insights, guidance and shared learning to help identify and address aspects of DOAC practice that may lead to harm.
Patient harm
DOACs carry inherent safety risks, particularly the risk of major haemorrhage, and anticoagulants are consistently represented in reports of serious or fatal medication‑related harm. Harm can also occur when DOAC doses are missed, increasing the risk of preventable thromboembolic events.
Several factors can make the safe prescribing, dispensing, and administration of DOACs more complex. This 16-minute video explores safety incidents involving DOACs and highlights some of the challenges associated with their safe use.
Clinical use
DOACs are approved for a range of indications relating to anticoagulation.
They are considered ‘time-critical’ medicines, and omission can result in significant harm, including an increased risk of stroke or venous thromboembolism (VTE). Understanding what makes a medicine time critical and how to promote timely use is discussed in our article Understanding time critical medicines to support improvement (SPS page).
NICE guidance relevant to DOAC use:
- Atrial fibrillation: diagnosis and management discusses the use of DOACs in people with atrial fibrillation.
- Venous thromboembolic diseases: diagnosis, management and thrombophilia testing discusses the use of DOACs for treating VTE. The guidance also covers anticoagulation for people at extremes of bodyweight, renal impairment, and cancer.
- Head injury: assessment and early management outlines assessment and management considerations for people taking DOACs who present with head injury.
Other relevant NICE resources:
- Clinical Knowledge Summaries: Anticoagulation – oral covers the management of adults receiving oral anticoagulant treatment (DOACs or warfarin) in primary care.
The UKCPA Handbook of Perioperative Medicines provides guidance on managing medications, including DOACs, before, during, and after surgery.
Safety directives
There are several MHRA Drug Safety Updates relating to DOACs. There is also a broader Drug Safety Update on prescribing medicines in renal impairment, which includes recommendations relevant to DOAC use.
The Health Services Safety Investigation Body (HSSIB) has published HSSIB investigation reports that include safety issues involving DOAC use.
Key strategies to improve DOAC safety
DOACs are prescribed across all sectors, and individuals taking DOACs will engage with HCPs in different care settings. A systemwide approach is needed to support the safer use of DOACs.
Given the scale of challenges associated with DOAC safety, it can be helpful to initially focus on specific patient groups or clinical settings. A range of strategies can be implemented to improve safety, either individually or in combination.
Anticoagulation stewardship
Anticoagulation stewardship is defined as a sustainable, efficient and coordinated system-level initiative to achieve optimal anticoagulant-related health outcomes and reduce avoidable adverse drug events.
This 18-minute video discusses anticoagulation stewardship and how core elements can be implemented within organisations.
Professional collaboration
Multi-professional anticoagulation and thrombosis teams can help to improve DOAC safety through specialist input. Local services can be effective at supporting HCPs with specialist advice.
This 20-minute video highlights the AF WAY project, run by the West Yorkshire Integrated Care Board (ICB). The project includes an ‘Advice and Guidance’ service for primary care HCPs, as well as the development of a DOAC tool.
This 7-minute video presents key findings from anticoagulant safety audits carried out as part of the NHS England Community Pharmacy Quality Scheme and demonstrates the role that Community Pharmacy has in promoting DOAC safety.
Utilising digital tools
Digital tools can support accurate monitoring and dosing of DOACs by helping to identify risk factors (such as reduced creatinine clearance) and prompting appropriate dose selection.
The AF WAY video (see the section on professional collaboration above) provides an example of where digital tools have been used to promote DOAC safety.
A HSSIB report on electronic prescribing and medicines administration (EPMA) systems and safe discharge highlights opportunities for digital systems to reduce harm, such as prevention of dual anticoagulant prescribing.
Upskilling healthcare professionals
HCPs should be equipped with the skills to promote safer use of DOACs.
The Specialist Pharmacy Service (SPS) has several resources relating to DOACs.
Several organisations have resources to help upskill HCPs. For example:
- Thrombosis UK’s training resources are aimed at hospital staff
- NHS England’s e-VTE resource is designed to help raise awareness and improve understanding of VTE
- Centre for Pharmacy Postgraduate Education (CPPE) support pharmacy professionals in anticoagulation practice
Communication at the care interface
If a DOAC is initiated or changed, HCPs should document this clearly in the person’s medical notes and communications. HCPs should ensure the person’s GP is informed of changes made in secondary care, and it is also good practice to document counselling provided to patients.
Clear documentation and communication of responsibility for monitoring, follow‑up, and ongoing supply helps ensure continuity of care.
Standardised practice
Where possible, roles and responsibilities should be clear and understood across the system. Clear policies and guidelines can help to ensure that DOACs are monitored and reviewed appropriately.
In this 16-minute video, Ben Leung discusses his success integrating DOACs into the Discharge Medicines Service (DMS). This includes standardising a DOAC counselling checklist for use across the system.
Introducing an intervention
Prior to implementing an intervention, it’s important to understand how it fits within current systems and processes and to consider any possible unintended consequences. Outcomes should also be defined in advance to enable effective evaluation of the intervention.
This 6-minute video features Ruth Dale from the NHS Medicines Safety Improvement Programme on implementing improvement and creating change.
Patient engagement and education
People taking DOACs should receive both written and verbal information about their treatment. This should include when and how to seek medical attention, as well as the signs and symptoms of over‑ or under‑anticoagulation. Where possible, counselling should be tailored to the individual’s needs and lifestyle.
Thrombosis UK have a range of patient information resources, including:
- Thrombosis UK patient information booklets and fact sheets
- Thrombosis UK patient information films and recordings
This 9‑minute video explores the importance of personalised care and engaging patients in discussions and decision-making about their treatment.
Shared good practice
Sharing experiences with improvement interventions can help to prevent duplication, support efficient use of resources and promote standardised practice across the NHS. Examples of exemplar practice, and a discussion board to network with peers, can be found on the MSATS FutureNHS workspace.
Full webinar recording
The SPS Medication Safety across the System (MSATS) series of webinars Developing Medication Safety Across The System (MSATS) (SPS page) are interactive sessions aimed at HCPs working in any sector with a role within or passion for medication safety.
The recording of the full MSATS: Safe use of DOACs webinar is available in the 90-minute video below. Information presented during the webinar and associated videos was correct at time of recording. Current guidance should be followed.