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Joint Commission issues recommendations for anticoagulation therapy, safety
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The Joint Commission issued a Sentinel Event Alert and held a press conference to address the safety of anticoagulant therapy. The alert offers recommendations and information about medication errors and the drug-related risks of heparin, warfarin and low–molecular-weight heparin.
“This alert brings attention to the issues of medication errors, specifically the anticoagulation errors, and these errors are preventable,” said Peter Angood, MD, vice president and chief patient safety officer of The Joint Commission, during the press conference.
According to the alert, unfractionated heparin, warfarin and low–molecular-weight heparin are among the anticoagulants cited most frequently in medication error reports and are also most commonly used.
When considering patients for therapy with anticoagulants, the commission urged screening be conducted to identify contraindications and drug interactions. While being treated with anticoagulant therapy, patients should be closely monitored for side effects and to prevent overdosing, while ensuring effectiveness of treatment.
In the alert and during the conference, the commission cited factors that contribute to anticoagulant-related errors:
- Confusion due to a lack of standardization for the naming, labeling and packaging of anticoagulants.
- Challenge for health care providers to stay up to date on dosing regimens, new assay methods, additional drug interactions and potential reversal strategies.
- Failure to document or communicate individualized instructions or monitoring information during transfers or hand-offs.
- Treatment of neonates or pediatric patients.
“The reason these medications are so difficult when it comes to errors is that the difference between an appropriate and lifesaving dose and an excessive or insufficient dose is extremely narrow. A little bit too much can cause severe bleeding and too little can fail to prevent the clotting problem that the medication was intended for,” said Mark Chassin, MD, MPP, MPH, president of The Joint Commission, during the press conference.
Reducing the risk for error
The commission recommended the development and implementation of risk reduction strategies to minimize error and harm from anticoagulation therapy. They also recommended the strategies be executed by all personnel involved in the administration of anticoagulant therapy, including physicians, nurses, pharmacists, dietitians and case managers.
The commission recommends guidelines issued by the United Kingdom’s National Patient Safety Agency, the Institute for Safe Medication Practices and the Institute for Healthcare Improvement. These guidelines urge staff communication and access to information, the application of close pharmacy oversight and involvement and improvements in patient education.
In addition, the commission recommended developing a pharmacist-managed anticoagulant service to help discharge patients receiving warfarin therapy and help staff manage patients on various types of anticoagulant therapy. The use of computerized provider order entry or bar coding technology was also recommended to assist pharmacies in replenishing stock and automated dispensing cabinets.
For more information:
- For more information visit www.jointcommission.org.