National Quality Forum (NQF) Releases Anticoagulation Stewardship Playbook to Help Improve Patient Safety 

AUG 24, 2022

CONTACT: Zachary Brousseau

National Quality Forum (NQF) Releases Anticoagulation Stewardship Playbook to Help Improve Patient Safety
New guide from NQF, in partnership with Anticoagulation Forum and with funding from FDA, offers proven strategies to reduce preventable adverse drug events

Washington, DC – The National Quality Forum (NQF), in partnership with the Anticoagulation Forum (AC Forum), and with funding from the U.S. Food and Drug Administration (FDA), has released Advancing Anticoagulation Stewardship: A Playbook, a new, publicly available guide to help healthcare organizations implement evidence-based strategies to promote patient safety in the use of anticoagulant medications.

More than 8 million people in the U.S. currently take anticoagulants, which work by decreasing the blood’s ability to clot. They are essential and life-saving for people with cardiac and vascular disorders, but have been identified as the most common cause of adverse drug events (ADEs) across various healthcare settings.

While errors in anticoagulants’ administration or dosage can cause life-threatening bleeding or other adverse events, Anticoagulation Stewardship offers a proven approach for reducing their likelihood, according to a review by the AC Forum (PDF). Such efforts represent a significant opportunity to minimize preventable patient harm, which was identified as an urgent need in a recent report from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG).

Anticoagulation Stewardship is defined as a coordinated, efficient, and sustainable system-level initiative designed to achieve optimal anticoagulant-related health outcomes and minimize avoidable ADEs. It has been shown to be successful in improving health outcomes, increasing efficiency, and reducing costs. Effective stewardship is associated with reductions in drug-drug interactions, bleeding events, hospital readmissions, length of stay, and other healthcare expenditures. Mounting published evidence (PDF) describes how organizations that have implemented Anticoagulation Stewardship programs have achieved cost savings of up to $4 million and cost avoidance of up to $3 million.

“Anticoagulants help save countless lives and lead to better health outcomes for so many people, but managing and monitoring their use is complex, and some of the associated risks are very serious,” said Dana Gelb Safran, ScD, President & CEO, NQF. “Anticoagulation Stewardship offers effective, evidence-based strategies to mitigate these risks and increase patient safety. This Anticoagulation Stewardship Playbook gives healthcare organizations a practical guide to implementing this approach that can be tailored to their unique needs and resources.”

The AC Forum, in partnership with FDA, identified seven Core Elements for improving systemic management of anticoagulants. The Playbook, developed with input from more than 30 experts, offers detailed strategies for each Core Element and is designed to be used by organizations establishing or considering Anticoagulation Stewardship programs, as well as those with existing programs in place. While all seven elements are important in implementing a successful stewardship initiative, the complexity of the endeavor and coordination of care required make the first Core Element—securing the commitment of administrative leadership—a foundational priority for organizations to address.

“Anticoagulants have been consistently identified as the most common cause of adverse drug events across healthcare settings and recent data from the Centers for Disease Control and Prevention shows that the issue has reached a critical juncture,” said Allison Burnett, PharmD and AC Forum President. “System-level change is needed now to address this growing public health problem. As has been done successfully before with Antimicrobial Stewardship, Anticoagulation Stewardship needs to be required in all clinical care settings to assure the quality and safety of patient care.”

Advancing Anticoagulation Stewardship: A Playbook is available at no charge from the NQF Store. 



About National Quality Forum
The National Quality Forum (NQF) works with members of the healthcare community to drive measurable health improvements together. NQF is a not-for-profit, membership-based organization that gives all healthcare stakeholders a voice in advancing quality measures and improvement strategies that lead to better outcomes and greater value. Learn more at

About Anticoagulation Forum
The Anticoagulation Forum is the largest organization of anticoagulation management specialists dedicated to improving the quality of patient care. The ACF advances Anticoagulation Stewardship by educating healthcare professionals and advocating for clinical best practices. Learn more at