Editor's note: This feature explores problematic Joint Commission standards with expert advice from BOJ advisors. This month, Elizabeth Di Giacomo-Geffers, RN, MPH, CNAA, BC, CSHA, a healthcare consultant in Trabuco Canyon, CA, and former Joint Commission surveyor, is joined by guest columnist Eileen Willey, RN, MSN, CPHQ, PI director at St. Joseph Medical Center in Towson, MD, to discuss heparin error prevention. St. Joseph has decided to address risks associated with heparin based on lessons learned at other facilities.