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Joint Commission issues Sentinel Event Alert on anticoagulants

Quality Improvement Monitor, September 26, 2008

The Joint Commission this week issued a Sentinel Event Alert on anticoagulant use and medical errors.

This is not the first time The Joint Commission has targeted anticoagulants. Requirements introduced into the 2008 National Patient Safety Goals are set to hit the point of full implementation on January 1, 2009. The Joint Commission also addresses anticoagulants under the medication management standards.

Common factors in anticoagulant errors highlighted in The Joint Commission’s alert include labeling and packaging issues, documentation errors, communication failures, and inappropriate use of medication.

The alert offers 15 steps to error prevention, including:

An assessment of the risks involved in using anticoagulants like heparin and warfarin

Use of best practices or evidence-based guidelines to prevent errors using anticoagulants

Reassessment of labeling and storing of anticoagulants to avoid errors

Greater communication and collaboration between staff members

More extensive education for patients

For more information, click here.