Recurring concern
Unsafe anticoagulant management
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Request correctionFirst reported 5 Sep 2013•Latest report 28 May 2026
What this concern includes
Includes failures of controls specifically dedicated to anticoagulant management, including prescribing clarity and reconciliation, anticoagulation-chart accuracy, INR or other required monitoring, senior clinical review, risk-sensitive guidance, escalation and consideration of anticoagulant treatment in relevant clinical circumstances.
Not included
- Excludes generic medication-prescribing, record-keeping, staffing, training or communication deficiencies unless they are specifically tied to anticoagulant management.
- Excludes general bleeding-risk controls for patients taking antithrombotic medication when the assertion does not concern anticoagulant management itself.
- Excludes medication administration, supply or continuity failures where anticoagulant treatment management is not the identified unsafe condition.
- Excludes unrelated thromboprophylaxis, venous-thromboembolism prevention and non-anticoagulant medication concerns.
- Reports
- 25
- Individual concerns
- 34
- Date range
- 2013–2026
- Stated actions
- 28
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Inadequate training of paramedics about bleeding dangers in patients prescribed newer anticoagulant drugs after a fall
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Publish Clinical Notice 18 to clinicians, covering Novel Oral Anticoagulants including Rivaroxaban and providing advice on their use.
Stated by Welsh Ambulance Services NHS Trust
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Concerns raised1
Administration of anticoagulation medication following a head injury
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Advising on Apixaban and other medications beyond six authorised medications falls outside an EMT’s scope of practice.
Stated by North West Ambulance Service NHS Trust
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Concerns raised1
Delays in reversing anticoagulation and administering blood transfusions
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Delays in Heparin-level testing and result availability
Unsafe use of unfractionated Heparin
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Alter the thrombolysis pulmonary embolism guideline to prompt checking prior heparin administration and careful APTT monitoring.
Stated by Barnsley Hospital NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The apparent 2-hour-37-minute APTT delay was actually 1 hour 20 minutes because the form was pre-prepared.
Stated by Barnsley Hospital NHS Foundation Trust
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Concerns raised1
Lack of literature informing anticoagulant therapy patients about the symptoms of a brain bleed
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing anticoagulant information, including the Yellow OAT book, NHS Choices guidance and NICE support, addresses patients’ need for bleeding-symptom advice.
Stated by NHS England
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Concerns raised1
Failure to use a sufficiently refined method for anticoagulant dose assessment
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Evidence and manufacturer guidance do not support routine anticoagulant dose adjustments for overweight patients without evidence of efficacy and safety.
Stated by Stockport NHS Foundation Trust
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Concerns raised3
Failure to consult a haematologist before heparin infusion for very low-weight patients
Failure to weigh patients before commencing heparin infusion
Failure to obtain baseline bloods and subsequent APTT monitoring for heparin administration
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Introduce an unfractionated-heparin chart and weight-based guideline with six-hour APTT checks and consultant escalation for abnormal results at extreme weights.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Weight-based dosing, six-hour APTT checks and conditional haematology advice are considered sufficient safeguards without routine consultation for extreme patient weights.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Concerns raised1
Failure of clinicians managing pregnant women with mechanical heart valves to understand the thrombosis risk and anticoagulation implications
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Unmonitored over-anticoagulation following omitted delegated INR testing
Non-uniform implementation of monitoring practices for delegated INR testing
Risk of unmonitored or unactioned failure to complete delegated INR testing
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to advise the pharmacy of Warfarin withdrawal due to lack of INR safety testing
Failure to implement notification of failed attendance for INR testing
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026