Joint Commission Offers Strategies for Preventing Anticoagulant Errors

Cheryl A. Thompson

With many health care organizations facing a January 1 deadline for making anticoagulant therapy a less dangerous treatment for patients, the Joint Commission today offered 15 strategies for preventing errors with anticoagulant drugs.

"This Sentinel Event Alert," said Peter B. Angood during a podcast by the Joint Commission, "is being issued in an effort to not only improve the awareness for the problems associated with anticoagulants but also to help organizations learn better how to insert or develop the systems and processes . . . to help these errors from not occurring and harming patients."

Angood is the Joint Commission's chief patient safety officer and a vice president of the accrediting organization.

Hospitals, outpatient clinics, long-term-care facilities, and home care organizations accredited by the Joint Commission must, by the start of 2009, be performing the eight so-called elements of performance for the safety requirement "Reduce the likelihood of [patient] harm associated with the use of anticoagulant therapy." This requirement is widely known as National Patient Safety Goal 3E, although the Joint Commission earlier this year renumbered the goals; the requirement's new designation is NPSG.03.05.01.

Today's alert, which states that its focus is on unfractionated heparin, warfarin, and low-molecular-weight heparins, divides the strategies into three categories: all anticoagulants, heparin, and warfarin.

Among the suggestions are to clarify all anticoagulant dosages for pediatric patients and eliminate heparin flush of peripheral i.v. lines. Also, verify the indication for warfarin use and contact the prescriber before automatically discontinuing the therapy in accordance with an automatic stop policy.

In general, the Joint Commission said, accredited organizations should consider implementing relevant suggestions offered in an alert.