New Sentinel Event Alert addresses blood thinners

Anticoagulants once again hit center stage

Anticoagulants, or blood thinners, have taken the mainstream media by storm with salacious tales of medical errors and tragic stories of babies' deaths. While you are dealing with the phase-in period on National Patient Safety Goal 3E, another call for alarm has been sounded on anticoagulant use and management.

The Joint Commission's new Sentinel Event Alert urges greater attention to be paid to this high-risk set of medications. (For the complete sentinel event information, including suggestions, visit

Also, in preparation for implementation by Jan. 1, 2009, The Joint Commission says hospitals should now have completed pilot testing on strategies for managing blood thinner use in conjunction with NPSG 3E. "As hospitals are struggling to come into compliance, we know a lot of them are actually behind," says Sue Dill Calloway, RN, MSN, JD, director of hospital patient safety at OHIC Insurance Co./The Doctors Company in Columbus, OH. "We've heard a lot of hospitals say that there's just no way they can meet that deadline."

Recommendations in the newest Sentinel Event Alert include:

  • 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 at higher risk because these drugs are formulated and packaged for adults.

Why now?

"The Joint Commission has had medication management standards in place for a long time," says Frank Federico, RpH, content director, Institute for Healthcare Improvement. "The fact that we're highlighting the anticoagulants, as they have with the National Patient Safety Goals, is just because it's not happening. We're not seeing improvements."

The problems that are occurring are numerous and multidimensional. But telling staff to just work harder, to be more vigilant, to pay more attention is not the answer, says Federico. And Mark Chassin, MD, MPP, MPH, president of The Joint Commission, agrees.

"It is important that we stop relying on the idea that if only everyone in the medication delivery process tried harder that doctors, nurses, pharmacists, and other caregivers could eliminate every single error by just trying harder," he said in a press conference on the new alert.

Where errors are occurring

In general, Chassin said, this set of drugs is challenging because the difference between a harmful dose and an appropriate one is so narrow. Peter Angood, MD, vice president and chief patient safety officer at The Joint Commission, said compliance is hampered by these persistent problems: the storage of the medication, the legibility of written orders, and the transcription of the orders.

"The cases show that errors occur at every stage the medication is processed — from ordering, to transcribing or documenting, dispensing, administering, and monitoring. And they happen in almost every unit in the hospital," said Diane Cousins, RpH, vice president, Center for the Advancement of Patient Safety, United States Pharmacopeia.

Some of the most frequent errors occur in admissions, she added, including:

  • failure to administer a single dose but also failure to initiate a course of therapy when it's ordered;
  • failure to resume therapy (for example, after surgery).

Among the top 10 most frequent causes for harm, she listed:

  • poor communications;
  • knowledge deficits among health care personnel;
  • inadequate or absent monitoring;
  • inaccurate computer entry, including computerized physician order entry;
  • performance deficits, in which trained personnel still make errors because of distractions, workload increases, and inexperienced staff.

So what can we do about it?

Federico says all health care professionals should look at the errors occurring across the United States and ask themselves, "Could this happen here?" Process evaluation and improvement are essential.

The second thing he stresses is taking a system approach. "Although education and training are necessary, they are not sufficient," he says, especially in lieu of sound system development.

Chassin said health care organizations should take a look at other companies in other industries and reliable systems that "anticipate, look for, track the small errors that people make every day before they result in harm." The first step, he said, should be undertaking an in-depth assessment to evaluate "how these processes fail."

Angood added that patients, before receiving anticoagulant therapy, should be screened for the "appropriateness" of receiving the medication and for any possible contraindications or adverse drug reactions.

He also emphasized that hospitals should standardize the way blood thinners are "prescribed, delivered to the bedside, and administered," strengthen communication about lab values, and determine dose limits when dosing is out of the "usual and expected" range. This last point, he said, should always be a checkpoint. "Unless there's a specific physician order that says, 'Yes, that's an OK dose,' those drugs should not be administered."

Cousins recommended all caregivers in the hospital setting "understand what the proper dosing is and stay up to date on proper dosing regimens. They should be aware of what those products look like and the various strengths that are available."

Federico suggests minimizing look-alike, sound-alike medications and emphasizes the importance of monitoring the patient. Some facilities, he says, use clinical pharmacists in the monitoring role because they can "monitor lab values, monitor patients, and make appropriate adjustments."

He also stresses identifying and managing high-risk patients: the frail and elderly and infants. It's a much different discussion with these patients than dealing with a healthy "normal" patient. Federico says two questions must be asked. First, can the patient comply with the regimen? Second, what's the risk of putting this patient, for example, on warfarin vs. not putting the patient on warfarin?

"Those are the kinds of issues that I think are the next step in the evolution toward a safer system," Federico says.

Another central element to anticoagulation management: education while patients are in the hospital and upon discharge. "There are some studies out there that report that self-managed anticoagulation is probably better than some of the other methods out there, Federico says. So an engaged patient who knows what to look for and when to call for help is probably a much better-cared-for patient."

Lastly, he emphasizes that anticoagulants are effective drugs and save many lives. "So the message we want to send out is we don't want to create so much fear that people won't use them. What we want to do is develop systems so people use them safely."

(Editor's note: Revisit the guidelines for National Patient Safety Goal 3E for new notations and clarifications.)