Article Text

Download PDFPDF

Using Lean Six Sigma methodologies to reduce risk of warfarin medication omission at hospital discharge
  1. Ashlie Kallal1,
  2. David Griffen2,
  3. Cassie Jaeger3
  1. 1 Pharmacy, Memorial Medical Center, Springfield, Illinois, United States
  2. 2 Emergency Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, United States
  3. 3 Operations Improvement, Memorial Health System, Springfield, Illinois, United States
  1. Correspondence to Dr Cassie Jaeger; Hawk.Cassie{at}


Unintended omission of warfarin, an anticoagulant used to prevent and treat thromboembolic events, can lead to serious medical complications. These complications include increased medical costs, hospitalisations and significant patient harm, including increased risk of thrombosis and mortality. Chart review of discharged patients at our institution revealed an average of one patient/month with warfarin omitted from the discharge plan despite intention to continue therapy. Lean Six Sigma methodology was used to improve the process. A system alert was implemented in the electronic health record to alert providers of patients who received warfarin during admission, the discharge medication reconciliation was complete, and there was no prescription for warfarin. Date and time of last warfarin dose and international normalised ratio were included in the alert. Providers had the option to return to the chart to update the discharge medication plan and add the warfarin prescription or to choose an appropriate over-ride reason. The number of patients discharged without an intended warfarin prescription following alert implementation was reduced from 10.5% (4/38) to 0% (0/40) (two proportion test, p=0.03). Alert tracking enhanced the ability to identify patients at risk for warfarin omissions. Process sustainability has been achieved by embedding system alerts in the electronic health record to trigger process steps.

  • adverse events
  • healthcare quality improvement
  • medication safety
  • epidemiology and detection

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

View Full Text

Statistics from


  • Contributors AK contributed to the study concept and design, acquisition of data, analysis of data, drafting of the manuscript, and study supervision. DG contributed to the drafting and critical revision of the manuscript. CJ contributed to analysis of data, drafting of the manuscript, and critical revision of the manuscript. All contributors reviewed the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval This submission has been reviewed by the local institutional review board. It was determined that this project was not research involving human subjects.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.