Assess anticoagulants to meet new requirement

Policy should address precautions for blood thinners

Compliance with The Joint Commission's National Patient Safety Goal (NPSG) 3 in 2008 will require accredited organizations to pay close attention to their assessment and monitoring of patients who are on anticoagulation therapy.

With one death every day and approximately 1.3 million people injured annually due to medication errors,1 it is no surprise that reducing the risk of patient injury due to medication error is a safety goal for the Joint Commission.

While Goal 3, "Improve the safety of using medications," always has been a safety goal, it is regularly reviewed and requirements for meeting the goal are adjusted as needed, says Peter B. Angood, MD, vice president and chief patient safety officer for The Joint Commission. The 2008 addition to Goal 3 is requirement 3E, which states that organizations must "reduce the likelihood of patient harm associated with the use of anticoagulation therapy."

"This topic [anticoagulation therapy] has surfaced in our Sentinel Events Advisory Group's reviews quickly in the past couple of years," says Angood. Anticoagulation therapy can be safe for patients "if they are monitored carefully by their primary care doctor to make sure that the correct dose is taken," he says. While surgeons and outpatient surgery center staff do not have responsibility for initial implementation of the therapy or for long-term monitoring, it is critical that they be aware of the patient's use of anticoagulants, he says.

One difference in requirement 3E's implementation from previous years' new goals is a specific timetable for implementation, says Angood. "In past years, we have identified a goal and given organizations one year to prepare for implementation," he says. The one-year timeframe gave organizations a sense that there was no need to do anything for one year, Angood admits. The checkpoints outlined in the rationale for requirement 3E calls for assignment of leadership responsibility by April 1, 2008; implementation work plan in place by July 1, 2008; pilot testing in at least one clinical unit by Oct. 1, 2008; and full implementation by Jan. 1, 2009. "These checkpoints should help organizations better prepare for full implementation," he adds.

Many outpatient surgery programs can incorporate the identification of anticoagulant use in their initial pre-op assessments or at whatever point staff members begin to gather information on the medications that patients are using, says Angood. In addition to identifying the patient's use of anticoagulants, the outpatient surgery staff should have specific protocols to follow to manage the patient preoperatively, he adds. These protocols may require stopping the medication at a certain point before surgery, if it can be done safely, he says. Surgery programs also must include specific patient education upon discharge to make sure that patients know when to resume the anticoagulation therapy, he points out.

Checklist highlights blood thinners

Staff members at Manatee Surgical Center in Bradenton, FL, are ready for the new patient safety goal, says Linda M. Nash, MBA, CASC, LHRM, administrator of the center. "We addressed anticoagulation therapy this year because we noticed an increasing number of patients using a lot of different types of anticoagulation therapies," she says. With the variety of therapies, Nash and her staff noticed that not all patients even realized they were on anticoagulation therapy, she says.

The pre-anesthetic form that is completed on the day of surgery was redesigned to list specific anticoagulation therapies for patients to select, says Nash. It was important to identify the specific medications to make sure patients remembered to tell them about the blood thinners, she says. [See a copy of the surgery center's pre-anesthetic evaluation] "The form is given to patients in the physician's office at the time surgery is scheduled," she points out. This gives the physician or the physician's staff a chance to talk to the patients about when to stop their anticoagulation therapy, then the surgery center staff verify the use of blood thinners when the preoperative call is made, she says.

In addition to making sure that they identify patients who are using blood thinners, Nash's staff created a list of each surgeon's specific needs regarding the stopping and restarting of anticoagulants, says Nash. "This list is posted on every clipboard in pre-op so that no matter which patient's chart is being reviewed, the nurse knows what that patient's surgeon requires with anticoagulants," she says.

It is not possible to develop just one list for all surgeons unless your center performs only one type of procedure, points out Nash. "The protocol for cataract surgery usually doesn't require the patient to stop taking his or her anticoagulant because the procedure is clean," she says. "On the other hand, a patient undergoing a colonoscopy during which polyps might be removed will be asked to discontinue blood thinners prior to the procedure."

Be sure to address patient education and restart of anticoagulants, suggests Angood. "A surgery center should educate the patient about the right time to restart medications and should review the proper dosage and timing of the medication," he adds.

Staff education also is important, says Nash. "Not all anticoagulants can be started immediately after surgery, so staff members need to understand what medications and what situations require different protocols," she says. For example, if a patient underwent a colonoscopy but had no polyps removed, it is fine to start anticoagulants immediately, she says. If, however, polyps are removed during the procedure, the nurse needs to verify how long the patient should remain off anticoagulant therapy, she adds.

Requirement 3E is the only new addition to The Joint Commission National Patient Safety Goals for ambulatory and office-based surgery programs for a reason, points out Angood. "We are aware that new goals or new requirements create a need for our accredited organizations to re-evaluate systems and procedures," he says. "Our field review demonstrates that organizations are coming up to speed on the goals, so we eased off on the number of new goals that organizations must address in 2008."


  1. Food and Drug Administration. Medication errors. Accessed at


To see a copy of the 2008 National Patient Safety Goals and implementation expectations, go to Select “Patient Safety” on the top navigational bar, then choose “National Patient Safety Goals.” Select “Ambulatory Care and Office-Based Surgery” or “Hospital” to see the goals. Links to the appropriate manual chapters that describe the rationales and implementation expectations are at the top of the page.