THE JOINT COMMISSION
The Joint Commission
The Joint Commission is an independent accreditation organization that addressed anticoagulant safety in its National Patient Safety Goals (NPSGs) and in a 2008 "Sentinel Event Alert."
NPSG 03.05.01
The goal of NPSG 03.05.01 is to increase the safety of anticoagulant therapy because "anticoagulation medications are more likely than others to cause harm due to complex dosing, insufficient monitoring, and inconsistent patient compliance."1
Elements of performance goals from NPSG 03.05.01 include 1:
- Use of approved protocols for initiation and maintenance of therapy
- Management of potential food and drug interactions
- Education for prescribers, staff, patients, and families
- Evaluation of anticoagulation safety practices
Sentinel Event Alert
The Alert offers additional recommendations to reduce the risk of anticoagulation medication errors. Recommendations include2:
- Performing risk assessments for anticoagulation therapy in the organization
- Following best practices or evidence-based guidelines regarding anticoagulation use
- Establishing standard dose limits on anticoagulants and requiring that a healthcare professional confirm any exceptions
- Clearly labeling syringes and other containers used for anticoagulants
- Educating and assisting inpatients to practice administering their own medication to help prevent errors after hospital discharge
References:
- Ambulatory health care: 2011 national patient safety goals [presentation]. The Joint Commission Web site. http://www.jointcommission.org/ahc_2011_npsgs. Accessed May 11, 2011.
- Sentinel Event Alert: Preventing errors relating to commonly used anticoagulants. The Joint Commission Web site. http://www.jointcommission.org/sentinel_event_alert_Issue_41_preventing_errors_relating_to_commonly_used_anticoagulants. Published September 24, 2008. Accessed May 20, 2011.
