Implementation of a Structured DOAC Initiation Form to Improve Prescribing Safety in Older Adults

Introduction:
Direct Oral Anticoagulants (DOACs) are increasingly prescribed for atrial fibrillation (AF), and venous thromboembolism (VTE). In geriatric populations, prescribing is complex due to comorbidities, polypharmacy, reduced renal function, and increased bleeding risk. Errors in prescribing or inadequate patient information can lead to adverse outcomes. To address this, a structured DOAC Initiation Form was introduced to standardise prescribing practices, reinforce guideline adherence, and improve patient education.

Methods:

A multidisciplinary team conducted two Plan-Do-Study-Act (PDSA) cycles.

PDSA Cycle 1 focused on developing a paper-based "DOAC Initiation Form". It includes 2 sections. Section 1 documents clinical indications, Creatinine clearance according to Cockcroft-Gault Equation, DOAC choice, dosing, and treatment duration. A checklist ensures patients or carers receive counseling on risk–benefit rationale, bleeding risk, side effects, lifestyle considerations, and annual monitoring. Section 2 provides standardised prescribing information for Non-valvular AF and VTE. The information is displayed for 4 common medications: Apixaban, Rivaroxaban, Edoxaban and Dabigatran, with clear dose adjustment criteria based on creatinine clearance, age, weight, and concomitant medications.

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.

Results:
Implementation of the form improved documentation, prescribers reported increased confidence in dose adjustments for frail older adults. The checklist ensured key safety points. Early feedback suggests the form reduced variation in prescribing practices and facilitated safer transitions of care through clearer documentation.

Conclusion:
A structured DOAC Initiation Form promotes safer, more standardised prescribing in older adults. By embedding guideline-based dosing and patient education into routine workflows, the form supports prescribers in addressing the complexities of geriatric care. Ongoing efforts will focus on electronic health record integration (PDSA 3) to sustain and enhance these improvements.