Navigation Links
Joint Commission Alert: Prevent Blood Thinner Deaths and Overdoses
Date:9/24/2008

Anticoagulant therapy linked to high rate of errors

OAKBROOK TERRACE, Ill., Sept. 24 /PRNewswire-USNewswire/ -- A number of recent high profile errors related to commonly used blood thinners highlight a safety issue that too frequently results in harm or even death to patients, according to a Joint Commission alert issued today that offers solutions to this medication safety issue.

The Joint Commission's new Sentinel Event Alert urges greater attention to the dangers associated with anticoagulants, life-saving medications that also present serious risks when administered incorrectly or in error. Patients being treated with these medications must be closely monitored and screened for drug and food interactions, given that commonly used anticoagulants such as heparin and warfarin 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.

Anticoagulant medication errors are such a serious patient safety issue that The Joint Commission addresses these types of errors in the 2008 National Patient Safety Goals, with full implementation of the requirements expected by January 1, 2009 for hospitals, outpatient clinics, home care and long term care organizations across the United States. In addition, The Joint 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," says Mark R. Chassin, M.D., M.P.P., M.P.H.., president, The Joint Commission. "The strategies contained in this Alert give health care organizations and caregivers the tools to make a difference in preventing anticoagulant medication errors."

The Joint Commission's 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.

-- Clarify all anticoagulant dosing for pediatric patients, who are higher

risk because these drugs are formulated and packaged for adults.

Other strategies for reducing the errors related to anticoagulants include staff communication and collaboration; patient education and participation; designating pharmacists to manage anticoagulant services; and use of computerized physician order entry (CPOE) and bar coding technology, if available.

The warning about preventing errors related to commonly used anticoagulants is part of a series of Alerts issued by the Joint Commission. Much of the information and guidance provided in these Alerts is drawn from the Joint Commission's Sentinel Event Database, one of the nation's most comprehensive voluntary reporting systems for serious adverse events in health care. The database includes detailed information about both adverse events and their underlying causes. Previous Alerts have addressed wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found on the Joint Commission's website (http://www.jointcommission.org).

Founded in 1951, The Joint Commission seeks to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission evaluates and accredits more than 15,000 health care organizations and programs in the United States, including more than 8,000 hospitals and home care organizations, and more than 6,100 other health care organizations that provide long term care, assisted living, behavioral health care, laboratory and ambulatory care services. The Joint Commission also accredits health plans, integrated delivery networks, and other managed care entities. In addition, The Joint Commission provides certification of disease-specific care programs, primary stroke centers, and health care staffing services. An independent, not-for-profit organization, The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care. Learn more about The Joint Commission at http://www.jointcommission.org.


'/>"/>
SOURCE The Joint Commission
Copyright©2008 PR Newswire.
All rights reserved

Related medicine news :

1. Mayo Clinic researchers discover new diagnostic test for detecting infection in prosthetic joints
2. Joint NJ/NY Rally for Addiction Recovery to Be Hub of Events Nationwide
3. Joint Juice Launches New Ready-to-Drink Glucosamine & Vitamin-Enhanced Dietary Supplement Water Nationwide
4. SAIC Selected to Support the U.S. Military Theater Medical Information Program-Joint
5. The impact of physical activity on weight-bearing knee joint
6. Joint Center Says New Approach Required to Reduce Black Infant Mortality
7. Merlyn Medical Announces FDA Approval for FlexWarmer in a Joint Agreement with Elltec and Suzuken
8. The Joint Commission Enhances Quality Check Website
9. OCS and Press Ganey Partner to Create Joint Analysis of Outcomes and Satisfaction
10. More Damage Than Good? Shock Survey Reveals Sport can Actually be bad for Your Joints
11. Delaware Court Approves Bioenvision, Genzyme Joint Petition
Post Your Comments:
*Name:
*Comment:
*Email:
(Date:6/25/2016)... Viejo, California (PRWEB) , ... June 25, 2016 , ... ... to fit their specific project," said Christina Austin - CEO of Pixel Film Studios. ... fully customizable and all within Final Cut Pro X . Simply select a ...
(Date:6/25/2016)... ... , ... On Friday, June 10, Van Mitchell, Secretary of the Maryland Department ... in recognition of their exemplary accomplishments in worksite health promotion. , The Wellness at ... Wellness Symposium at the BWI Marriott in Linthicum Heights. iHire was one of 42 ...
(Date:6/24/2016)... ... June 24, 2016 , ... June 19, 2016 is World Sickle Cell ... pain and the benefits of holistic treatments, Serenity Recovery Center of Marne, ... Cell Disease. , Sickle Cell Disease (SCD) is a disorder of the red blood ...
(Date:6/24/2016)... ... June 24, 2016 , ... Dr. ... accelerated orthodontic treatment. Dr. Cheng has extensive experience with all areas of orthodontics, ... and accelerated osteogenic orthodontics. , Micro-osteoperforation is a revolutionary adjunct to orthodontic ...
(Date:6/24/2016)... ... June 24, 2016 , ... EB Medicine presented its ... Emergency Medicine conference in Ponte Vedra Beach, FL. The awards honor the outstanding ... Medicine Practice and Pediatric Emergency Medicine Practice. , “With this award, we ...
Breaking Medicine News(10 mins):
(Date:6/24/2016)... According to a new market ... Needles, Safety Pen Needles), Needle Length (4mm, 5mm, 6mm, ... of Purchase (Retail, Non-Retail) - Trends & Global Forecasts ... market for the forecast period of 2016 to 2021. ... by 2021 from USD 1.65 Billion in 2016, growing ...
(Date:6/23/2016)... HOUSTON , June 23, 2016  MedSource ... platform as its e-clinical software solution of choice.  ... the best possible value to their clients by ... nowEDC.  The preferred relationship establishes nowEDC as the ... pricing for MedSource,s full-service clients.  "nowEDC has long ...
(Date:6/23/2016)...  In a startling report released today, National Safety Council ... a comprehensive, proven plan to eliminate prescription opioid overdoses. ... states are tackling the worst drug crisis in recorded U.S. history, ... Kentucky , New Mexico , ... the 28 failing states, three – Michigan , ...
Breaking Medicine Technology: