Project Information

Use of an Epic-based scoring system to identify at-risk patients in need of anticoagulant dose adjustment due to renal insufficiency

Project Description: Therapeutic anticoagulation is frequently used in the treatment of deep vein thrombosis (DVT), pulmonary embolism (PE),acute myocardial infarction, and other thrombotic conditions. Several commonly used anticoagulants are eliminated renally and dose adjustments are required in patients with renal impairment in order to reduce likelihood of serious bleeding events. Hospitalized patients on anticoagulant therapy frequently experience fluctuations in renal function that may require dosage adjustment after initiation. The challenge is identifying these patients quickly so that doses can be changed before adverse effects occur. Declines in renal function in patients on anticoagulants may go unnoticed for a variety of reasons. Additionally, changes in serum creatinine that remain within reference range may be perceived as normal despite a 50% or more increase from baseline. Several Patient Safety Reports (PSR) prompted a Medication Use Evaluation (MUE) to evaluate patients that had declines in renal function while receiving therapeutic enoxaparin. Out of 25 patients that had significant decline in renal function, 11 (44%) did not have their dose appropriately adjusted. Five of these patients experienced a bleeding event. In November, a process to identify patients on therapeutic anticoagulation therapy that experience a decline in renal function was created in Epic. A scoring system was created that “flags” patients by drug and degree of renal function. The output of this score is a customized icon that appears in a patient list column. This column is used by pharmacists to identify patients so that an appropriate dose adjustment can occur quickly when renal function declines.

QPI: Benjamin, Staley, (

Collaborators: Carrie, Lagasse, (; Amy, Rosenberg, (; Kristen, Dominick, (


UF Health Big Aims: Zero Harm None

MeSH Keywords: Anticoagulants, Enoxaparin, Bleeding, Renal Impairment, clinical decision support