Standards › Standard 47 › Policies
Policy · ANT-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 47.4
At a glance
- Every anticoagulant use is recorded at admission and at each change (ANT-REG-001).
- Dose is checked against renal function and weight at the interval set for each drug.
- Each patient on an anticoagulant has a written reversal plan for bleeding, specific to the drug.
- Reversal agents are stocked and checked as set in the plan.
- Stop and get help straight away if: a patient on an anticoagulant has no recorded reversal plan.
1. Purpose
To make sure anticoagulant use is recorded, dosed safely, and has a plan for reversal if bleeding occurs (47.4).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Anticoagulants prevent clots but cause bleeding if they are not dosed carefully. Checking the dose, and having a written plan to reverse them, keeps patients safe.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Prescriber | Records the drug and dose and writes the reversal plan | Clinical lead |
| Ward pharmacist | Checks the dose and the reversal agents | Clinical lead |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Record.
- Record the anticoagulant, dose and indication on admission and at each change (ANT-REG-001).
Key point: Recorded.
Step 2. Check.
- Check the dose against renal function and weight at the set interval.
Key point: Checked.
Step 3. Plan.
- Write the reversal plan for the drug, and check that the reversal agent is available.
Key point: Planned.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Anticoagulant patients with a recorded reversal plan | 100% | Monthly | Clinical lead | Escalate to the hospital director |
| Doses checked at the set interval | 100% | Monthly | Ward pharmacist | Review the dose at once |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| ANT-REG-001 | Anticoagulant use and reversal register | Register |
| CLN-SOP-005 | VTE risk assessment and prophylaxis (existing, reused) | SOP |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)