Joint Commission Alert: Prevent Blood Thinner Deaths and...(n preventinganticoagulant medication err...),Health

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
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