ED Accreditation Update

Sentinel Event Alert targets anticoagulants

The Joint Commission has issued a Sentinel Event Alert on "Preventing errors relating to commonly used anticoagulants."

The anticoagulants cited most frequently in medication error reports are unfractionated heparin, warfarin, and enoxaparin, classified as low molecular weight heparin (LMWH), says The Joint Commission.

The Alert says patients under consideration for receiving anticoagulant drugs must be carefully screened for contraindications and drug interactions. While receiving anticoagulants, patients must be monitored closely to ensure effectiveness and to prevent side effects or overdosing. Heparin and warfarin in particular have narrow therapeutic ranges and a high potential for complications, so there is a greater risk of patient harm, notes the alert.

Health care organizations that dispense or administer anticoagulant medications can prevent errors relating to anticoagulants by implementing specific risk reduction strategies, the Alert notes. Since the management of anticoagulants is interdisciplinary, any risk strategies should be implemented by all staff who manage anticoagulants, which can include physicians, nurses, pharmacists, dietitians, and case managers, it points out. The Alert adds that guidelines issued by organizations such as the Institute for Healthcare Improvement emphasize improving staff communication and access to information, implementing close pharmacy oversight and involvement, and enhancing patient education.

You can access the entire Alert at www.jointcommission.org. Under "Sentinel Event," click on "Sentinel Event Alert." Under "Index of Issues," click on "Issue 41 — Preventing errors relating to commonly used anticoagulants."