Abstract
Background Direct oral anticoagulants (DOACs) are increasingly used for stroke prevention in atrial fibrillation and treatment of venous thromboembolism. However, DOACs are high-risk medications; inappropriate prescribing or dosing can lead to adverse outcomes. This quality improvement (QI) project aimed to standardize the DOAC initiation process at a district general hospital to enhance prescribing safety and reduce errors. Methodology A multidisciplinary team conducted two Plan-Do-Study-Act (PDSA) cycles. PDSA Cycle 1 focused on developing a paper-based "DOAC Initiation Form" to guide prescribers through indication-based dosing, renal function checks, and patient counselling points. PDSA Cycle 2 implemented this form on medical wards with staff training. Key measures included the appropriateness of DOAC prescriptions (correct drug/dose for patient factors) and documentation of patient education. A third PDSA cycle to integrate the form into the electronic health record is in planning, but has not commenced at the time of this report. Results The DOAC initiation form was successfully created and introduced. In Cycle 1 (form development), stakeholder feedback (from physicians, pharmacists, and nurses) was incorporated to ensure usability and completeness of the form. In Cycle 2 (implementation), use of the form was associated with a marked improvement in prescribing quality. Post-implementation audits found that most DOAC prescriptions were appropriate for indication and renal function, with no major dosing errors identified, compared to multiple errors noted at baseline. Documentation of patient counselling and monitoring plans (e.g., renal function follow-up) increased substantially with the new form. Staff surveys indicated improved confidence in DOAC prescribing. The third cycle (digital integration) remains pending, expected to further streamline the process. Conclusions Introducing a standardized DOAC initiation form led to safer prescribing practices in our hospital. The first two PDSA cycles achieved improved DOAC prescription appropriateness and better documentation of patient counselling. Ongoing efforts will focus on electronic health record integration (PDSA 3) to sustain and further enhance these improvements. This project demonstrates that a structured prescribing process can mitigate errors and improve patient safety when initiating high-risk therapies such as DOACs.