A number of
recent high profile errors related to commonly used blood thinners
highlight a safety issue that too frequently results in harm or even death
to patients, according to a Joint Commission alert issued that offers
solutions to this medication safety issue.
The Joint Commission’s new Sentinel Event Alert urges greater attention
to the dangers associated with anticoagulants, life-saving medications that
also present serious risks when administered incorrectly or in error.
Patients being treated with these medications must be closely monitored and
screened for drug and food interactions, given that commonly used
anticoagulants such as heparin and warfarin have narrow therapeutic ranges
and a high potential for complications. Adding to the problem is a lack of
standardized naming, labeling and packaging of anticoagulants that create
confusion and lead to devastating errors.
Anticoagulant medication errors are such a serious patient safety issue
that The Joint Commission addresses these types of errors in the 2008
National Patient Safety Goals, with full implementation of the requirements
expected by January 1, 2009 for hospitals, outpatient clinics, home care
and long term care organizations across the United States. In addition, The
Joint Commission’s medication management standards require organizations to
pay particular attention to high-risk drugs such as anticoagulants in order
to improve safety.
“Anticoagulants are vital to maximizing the effectiveness of many
medical treatments and surgical procedures that benefit patients, but the
systems necessary to ensure that these drugs are used safely are not
adequate,” says Mark R. Chassin, M.D., M.P.P., M.P.H.., president, The
Joint Commission. “The strategies contained in this Alert give health care
organizations and caregivers the tools to make a difference in preventing
anticoagulant medication errors.”
The Joint Commission’s Alert highlights factors that contribute to
anticoagulant medication errors, including lack of standardized labeling
and packaging, failure to document and communicate patient instructions
during hand-offs, and inappropriate dosing for pediatric patients.
To reduce the risk of errors related to commonly used anticoagulants,
The Joint Commission’s Alert recommends that health care organizations take
a series of 15 specific steps, including the following:
— Assess the risks of using anticoagulants.
— Use best practices or evidence-based guidelines regarding
anticoagulants.
— Establish standard dose limits on anticoagulants and require that a
doctor confirm any exceptions.
— Clearly label syringes and other containers used for anticoagulants.
— Clarify all anticoagulant dosing for pediatric patients, who are higher
risk because these drugs are formulated and packaged for adults.
Other strategies for reducing the errors related to anticoagulants
include staff communication and collaboration; patient education and
participation; designating pharmacists to manage anticoagulant services;
and use of computerized physician order entry (CPOE) and bar coding
technology, if available.
The warning about preventing errors related to commonly used
anticoagulants is part of a series of Alerts issued by the Joint
Commission. Much of the information and guidance provided in these Alerts
is drawn from the Joint Commission’s Sentinel Event Database, one of the
nation’s most comprehensive voluntary reporting systems for serious adverse
events in health care. The database includes detailed information about
both adverse events and their underlying causes. Previous Alerts have
addressed wrong-site surgery, medication mix-ups, health care-associated
infections, and patient suicides, among others. The complete list and text
of past issues of Sentinel Event Alert can be found on the Joint
Commission’s website (jointcommission).
Founded in 1951, The Joint Commission seeks to continuously improve the
safety and quality of care provided to the public through the provision of
health care accreditation and related services that support performance
improvement in health care organizations. The Joint Commission evaluates
and accredits more than 15,000 health care organizations and programs in
the United States, including more than 8,000 hospitals and home care
organizations, and more than 6,100 other health care organizations that
provide long term care, assisted living, behavioral health care, laboratory
and ambulatory care services. The Joint Commission also accredits health
plans, integrated delivery networks, and other managed care entities. In
addition, The Joint Commission provides certification of disease-specific
care programs, primary stroke centers, and health care staffing services.
An independent, not-for-profit organization, The Joint Commission is the
nation’s oldest and largest standards-setting and accrediting body in
health care. Learn more about The Joint Commission at
jointcommission.
The Joint Commission
jointcommission
View drug information on Warfarin Sodium tablets.