The Joint Commission released today its latest Sentinel Event Alert targeting anticoagulant use and medical errors, the fourth alert this year. There have been a number of high-profile medical errors involving anticoagulants in the national media, and The Joint Commission’s alert is intended to offer methods for preventing further 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 report include labeling and packaging issues, documentation errors, communication failures, an inappropriate use of medication.
The alert offers fifteen 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 or to view the Sentinel Event Alert itself, go to The Joint Commission’s Web site here .