The Joint Commission has released the new Sentinel Event Alert, which urges greater attention to the dangers associated with anticoagulants, such as heparin and warfarin, which the agency defines as “life-saving medications that also present serious risks when administered incorrectly or in error.”
The commission said that patients being treated with the medications “must be closely monitored and screened for drug and food interactions, given that commonly used anticoagulants 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.”
The commission addresses these types of errors in the 2008 National Patient Safety Goals, with full implementation of the requirements expected by Jan. 1, 2009 for U.S. hospitals, outpatient clinics, home care and long-term care organizations. In addition, the 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,” said Mark R. Chassin, MD, president of the commission.
The commission said its 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; and
- Clarify all anticoagulant dosing for pediatric patients, who are higher risk because these drugs are formulated and packaged for adults.